ACLS 2005 What is new and why?

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ACLS 2005What is new and why?

• Morbidity Rounds
• Feb 15, 2006
• Rob Hall MD, FRCPC

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Overview

• Goal review major changes to CPR, ALS,
  electrical therapies, cardiac arrest, arrythmia
  algorithms, post resusc care
• Briefly review some Landmark papers.
• AEDs, ACS, CVA, toxicology and other special
  resusc situations not included

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ACLS 2005 Guidelines

• VISIT www.circulationha.org
• Circulation 2005. Dec 13 112(24) p3667-3813 and
  Supp 11 p 1-211.

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Global Comments

• BACK TO THE BASICS
• Increased emphasis on CPR
• Decreased emphasis on drugs
• SIMPLER
• Consistent ratios for CPR
• Less algorithms (PEA/Asystole out)
• Tachycardia much simpler
• EVIDENCE BASED
• Nice to see Landmark papers incorporated.
• Recognition of importance of survival to
  discharge vs survival to admission

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CPR/BLS
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Part 3/4 CPR/Adult BLS

• Lay Rescuers
• Lay rescuers not taught artificial respirations
  or pulse checks
• Lay rescuers taught to look for normal
  breathing
• Lay rescuers not taught the jaw thrust
• Age definitions
• Neonatal age applies to baby deliver up until
  they leave hospital
• Different age cut offs for Lay rescuers
• lt1year, 1-8 year, gt8 year (Lay rescuer)
• lt1year, 1-adolescent, gtadolescent to adult (HCP)

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Part 3/4 CPR/Adult BLS

• Ventilations
• Less important than compressions (EARLY)
• Ventilate enough to make chest rise
• Rate about 10 per minute after advanced airway
• AVOID over - ventilation (decreased venous
  return, decreased cardiac output)
• AVOID rapid/forceful breaths
• AVOID interruption of compressions after advanced
  airway placed

LOW AND SLOW ventilations
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Part 3/4 CPR/Adult BLS

• Compressions
• More important than ventilation
• Rate about 100 compressions per minute
• Push hard enough to compress the chest
• Allow full recoil of chest
• Allow equal time for compression and recoil
• MINIMIZE interruptions in compressions
• Synchronicity
• Unsynchronized ventilation/compression after
  advanced airway placed

HARD AND FAST compressions
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ED Interruptions in Compressions

• Transfer to ED bed
• Pulse checks
• Placing patient on the monitor and defibrillator
• Rhythm checks
• Vascular access
• Airway management
• Defibrillation
• Drug delivery
• Bedside ultrasound
• ABG draw
• Physical examination
• Changeover of compressor

• We should minimize CPR interruptions

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ACLS 2000
After Advanced Airway Device Placed 5
compressions to 1 ventilation (synchronized)
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ACLS 2005
After Advanced Airway Device Placed 100
compression/min 10 breaths per minute
(unsynchronized)
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ACLS 2005
After Advanced Airway Device Placed 100
compression/min 10 breaths per minute
(unsynchronized)
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Adult BLS Healthcare Provider Algorithm
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Electrical Therapies
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Part 5 Electrical Therapy
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Part 5 Electrical Therapy
Truncated Exponential
Rectilinear
Biphasic increased ROSC, no increase Survival
to hospital discharge
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Lifepak

• 12 and 20 are both biphasic (truncated
  exponential)

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Recommended Energy for Defibrillation
Lifepak 12 and 20
Peds 2 J/kg then 4 J/kg
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Recommended Energy for Cardioversion for Lifepak
12/20
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Timing of Defibrillation

• Shock First vs CPR First?

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Evidence for CPR before defibrillation

• Cobb JAMA 1999
• Prospective observational trial, N1117
• Pre-intervention defibrillate ASAP
• Post-intervention 90 sec CPR before defib
• Survival to d/c Defib First CPR
  First P NNT
• Overall 24 30 .04 16
• Response lt 4min 31 32 .87
• Response gt 4min 17 27
  .007 10

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Evidence for CPR before defibrillation

• Wik JAMA 2003
• Randomized clinical trial, N200
• Defibrillate ASAP vs CPR X 3 min before
  defibrillation
• Survival to d/c Defib First CPR
  First P NNT
• Overall 15 22 .17
• Response lt 5min 29 23 .61
• Response gt 5min 4 22
  .006 5.5

A priori subgroup analysis
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Evidence for CPR before defibrillation

• Jacobs. Emerg Med Australasia. Feb 2005.
• Randomized clinical trial, N256
• Defibrillate ASAP vs CPR X 90 sec before
  defibrillation
• Survival to d/c Defib First CPR First
  OR 95CI
• Overall 5.1 4.2 .81
  (.3-2.6)
• Survival to d/c Defib First CPR First
  P
• Response lt 5min 0 12 .25
• Response gt 5min 4.9 3.5
  .74

Post hoc subgroup analysis
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Timing of Defibrillation

• ACLS 2005 Recommendation
• CPR X 5 cycles of 302 (about 2 min) recommended
  for out-of-hospital VF arrest
• Response time gt 4-5 minutes
• Unwitnessed

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Part 6 CPR Techniques and Devices

• Non-traditional CPR and devices not universally
  recommended
• Recognition of growing evidence
• Optional for Health Care Providers
• Active Compression-Decompression CPR
• Mechanic pistons
• Load Distributing Band CPR/Vest CPR
• Research
• Thoracic-Abdominal Compression-Decompression CPR

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ALS
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Part 7.2 Management of Cardiac Arrest

• ACLS Pulseless Algorithm 2005
• Vfib Algorithm
• PEA Algorithm
• Asystole Algorithm

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Circulation 2005 112IV-58-66IV-
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Notes on VF and pulseless VT

• CPR 302 until defibrillator ready
• One shock, not three
• 150J (not 360J) Lifepak 12/20
• CPR X 2min right after shock (no rhythm check)
• Timing of intubation not specified
• Timing of vasopressor not specified
• Epinephrine 1mg or vasopressin 40IU
• Timing of antiarrythmic not specified
• Amiodarone 300mg or Lidocaine 1.5 mg/kg

Circulation 2005 112IV-58-66IV-
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Amiodarone for Vfib/pulseless VT

• ARREST TRIAL
• DBRCT, N504
• Amio vs Placebo
• Survival PL Amio P
• Admission 34 44 .03
• Discharge 13.4 13.2 NS

• ALIVE TRIAL
• DBRCT, N 347
• Amio vs Lidocaine
• Survival Lido Amio P
• Admission 12 23 .009
• Discharge 3.8 6.8 NS

Kudenchuk et. al. NEJM 1999. 341(12) p.871.
Dorian et. al. NEJM 2002. 346(12) p.884.
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Notes on pulseless PEA/asystole

• Focus is on quality CPR and look for and treat
  reversible causes
• Atropine
• Epinephrine or Vasopressin
• PACING is OUT!
• Three RCTS of prehospital transcutaneous pacing
  showed no benefit

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Why Vasopressin? Or why not

• Linder. Lancet 1997.
• N40, out of hospital Vfib, vasopressin vs epi
• Increased survival to admission not discharge
• Stiell. Lancet 2001.
• N200, in-hospital Vfib/PEA/asystole
• Vasopressin vs epi
• No difference in survival to discharge (power
  0.8)

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Vasopressin

• Wenzel. NEJM 2004. 350(2). P 105-113.
• DBRCT, N 1186
• Out-of-hospital vfib/PEA/asystole
• Vasopressin 40IU vs Epinephrine 1mg
• Survival all patients AVP EPI P
• Admission 36 31 .06
• Discharge 10 10 .99
• Survival Asystole AVP EPI P NNT
• Admission 29 20 .02
• Discharge 4.7 1.5 .04 31

Problem multiple subgroup analysis (29)
suspected type I (alpha) error
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ALS Tachy/Brady
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Bradycardia Algorithm
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Bradycardia Notes

• No major changes
• Increased emphasis on early pacing for unstable
  patients
• Atropine unlikely to work with infranodal
  blocks/escape rhythms
• 2nd degree type II AVB
• 3rd degree AVB
• Wide QRS escape rhythm

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Tachycardia Algorithm

• General Comments
• Much simpler
• Cardiac function/Ejection Fraction decision
  branches removed
• Less drugs listed at each box
• Less emphasis on trying to distinguish Vtach vs
  SVT aberrancy
• Nice approach ..

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ACLS Tachycardia Algorithm
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Wide QRS Tachycardia
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AFIB WPW

• Tijunelis. CJEM 2005. Vol7(4)p. 262-5.
• Literature review of Afib WPW treated with
  amiodarone
• No controlled studies
• 10 case reports
• 7/10 developed Vfib or unstable VT
• AMIODARONE NOT SAFE for AFIB WPW
• CARDIOVERSION is the treatment of choice

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Part 7.5 Postresuscitation

• Should we induced hypothermia post cardiac arrest?

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Induced HypothermiaNEJM Feb 2002 --what is the
evidence?

• Austrian Study
• RCT, N136
• Witnessed VF/pulseless VT
• Excluded Sats lt 85, hypotension gt 30 min,
  coagulopathy, etc
• 32-34 degrees X 24hrs
• Result cool warm NNT
• Neurofn 6mo 55 39 6
• Mortality 6mo 41 55 7

• Australian Study
• RCT, N77
• Initial VF rhythm then comatose
• Excluded SBPlt90 despite epi, non-primary-cardiac
  etiologies
• 33 degrees X 18hrs
• Result cool warm NNT
• Survival 49 26 4
• Outcome survival to discharge home or
  neurorehab unit

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Part 7.5 Postresuscitation

• ACLS 2005 Guideline for Induced Hypothermia
• Recommended for post Vfib arrest with ROSC but
  remains comatose
• Consider for non-VF arrest

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What really matters? CPR/BLS/Defib
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Why the emphasis on CPR and defibrillation?

• OPALS study
• Stiell. NEJM 2004. 351(7). P 647-656.

BLS Rapid Defibrillation
ALS care (ETT,iv,drugs)
N 1391 12 months
N 4247 36 months
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Why the emphasis on CPR and defibrillation?

• OPALS study
• Stiell. NEJM 2004. 351(7). P 647-656.

BLS Rapid Defibrillation
ALS care (ETT,iv,drugs)
Survival to 11 15 p.001 Admission Survival
to 5.0 5.1 p.83 Discharge
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Why the emphasis on CPR and defibrillation?

• OPALS study
• Stiell. NEJM 2004. 351(7). P 647-656.
• Logistic Regression OR for survival
• Witnessed arrest 4.4
• Bystander CPR 3.7
• AED lt 8min 3.4

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Take home points

• One shock (not three) for VF
• Lower energy with biphasic defibrillators
• Less emphasis on drugs
• More emphasis on CPR
• CPR 302 ratio
• CPR before defibrillation for response times gt 4
  minutes
• Quality CPR with minimal interruptions
• Should we call ourselves CPR-coaches?
• Why isnt CPR taught in high-school?