The 2015 BLS & ACLS Guidelines: What’s New?

National Teaching Institute New Orleans, LA Nicole Kupchik RN, MN, CCNS, CCRN, PCCN, CMC Independent CNS/Staff Nurse

Objectives • Discuss the updates to the 2015 guidelines. • Describe the importance of HIGH quality CPR including proper rate, depth, minimizing pauses & optimal chest compression fraction. • Discuss the recommendations for medications.

2015 ACLS/BLS Guidelines: https://eccguidelines.heart.org/ index.php/american-heartassociation/

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2015 Recommendations AHA Recommendations Class I – 25%

Class IIB – 45%

Class I (Strong)

Class IIA – 23%

Class IIA (Moderate)

Class IIB (Weak)

Class III (No Benefit)

Class III (Harm)

CPR Quality

What constitutes HIGH quality CPR? • • • •

Chest compression rate 100 – 120 / min Depth 2 – 2.4 inches Full recoil of the chest Minimizing pauses in CPR ▫ Chest compression fraction > 60% ▫ As high as possible! (>80%)

• Minimizing pauses with defibrillation ▫ < 5 seconds (European Resuscitation Council)

• Avoiding excessive ventilation ▫ 10 breaths per minute Circulation 2015, AHA BLS/ACLS Guidelines

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Chest Compression Fraction • The % of time spent providing compressions while the patient is pulseless • May also be called “compression ratio” • Goal: At least 80%! Is it acceptable to be off the chest for 20% of an arrest?

Positioning

Leaning & recoil – < 5’9”? Use a stepstool!

2015 CPR Quality Levels of Evidence – ILCOR/AHA Recommendation

Class LOE

Chest Compression Rate 100 – 120 / minute

IIa

Chest Compression Depth 2”- 2.4”

I

C-LD

Chest Compression Fraction >60%

IIb

C-LD

Minimizing Pre & Post-shock pauses

I

C-LD

Allowing full recoil of the chest wall

IIa

C-LD

Impedance threshold devices – NOT recommended

III

Artifact altering algorithms – Insufficient evidence

IIb

C-LD

C-EO

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Minute by minute breakdown

Mechanical Chest Compression Devices • Provides effective, consistent and uninterrupted compressions during: ▫ ▫ ▫ ▫ ▫ ▫

Intra-departmental transport Defibrillation Advanced procedures Cardiac Catheterization Long cases Limited resources

2015 Feedback & Mechanical Devices Levels of Evidence – ILCOR/AHA Recommendation

Class LOE

Using feedback devices to guide compression quality

IIb

B-R

The use of mechanical compression devices may be a reasonable for use by properly trained personnel. The use of mechanical compression devices may be IIb considered in specific settings where the delivery of high quality manual compressions may be challenging or dangerous to the provider.

C-EO

ECPR – Venous/Arterial ECMO may be considered for refractory cardiac arrest when the cause is likely reversible

C-LD

IIb

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AVOID Over-ventilation!!! • If patient does not have an advanced airway:

30:2 “Hyperventilation Do you stop compressions for ventilations? YES Kills”

• If the patient has an advanced airway:

10 breaths / min (1 breath every 6 seconds) -ECCU Conference 2015

Do you stop compressions for ventilations? NO -2015 BLS/ACLS Guidelines

2015 Capnography Levels of Evidence – ILCOR/AHA Recommendation

Class LOE

Continuous Waveform Capnography to verify ETT placement

I

C-LD

Low PEtCO2 (< 10 mmHg) after 20 minutes in intubated patients is strongly associated with failure of resuscitation

IIb

C-LD

Should not be used in isolation or in non-intubated patients as a marker to terminate resuscitation

III

Capnography as a measure of CPR quality Capnography as an indicator of ROSC

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Defibrillation

Ventricular fibrillation • Most successful treatment for v-fib is defibrillation! • For every minute delay, survival decreases by 10%!!!

Metoba et al (2010) Circulation

N = 13, 053

The 2nd most cited paper in Resuscitation in the 5-year period after it was published! Conclusion: Pause duration does affect VF termination rate.

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Pauses are bad. Very bad. • OHCA, observational study • Evaluated pauses in all rhythms including PEA & asystole • Survival decreased 11% per 5 second increase in duration of longest overall pause • Individual long pauses may be more harmful than multiple short pauses even if the overall CCF is similar Brouwer, Walker, Chapman, Koster (2015) Circulation 132:1030-37.

Compressions

37 sec non-shock pause

Compressions 20

21

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2015 Defibrillation Levels of Evidence – ILCOR/AHA Recommendation

Class LOE

For manual defibrillators, we suggest that pre & post shock pauses are as short as possible.

I

C-LD

Immediately resume chest compressions after shock delivery in adults in cardiac arrest in any setting

IIb

C-LD

Defibrillators with bi-phasic waveforms are preferred to monophasic for treatment of atrial or ventricular arrhythmias

IIa

B-R

Use manufacturer's recommended energy dosing

IIb

C-LD

Single shock strategy is suggested (vs. stacked)

IIa

B-NR

Drugs

Studies questioning the use, timing, efficacy of Epinephrine • • • • • • • • •

Dumas et al (2014) J Amer College of Card* Olasveengen et al (2012) Resuscitation* Hagihara et al (2012) JAMA* Jacobs et al (2011) Resuscitation* Olasveengen et al (2009) JAMA* Ong et al (2007) Ann Emerg Med* Gueugniaud et al (1998) NEJM Herlitz et al (1995) Resuscitation* Paradis et al (1991) JAMA *Epi associated with worse outcomes

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Is Epinephrine beneficial or does it cause harm?

• Current recommendation: 1 mg Q 3 – 5 min • • • • • •

RCT Epi vs. Placebo Warwick University UK & Wales Enrollment started Sept 2014 8,000 subjects Out-of-Hospital Cardiac Arrest

• Paramedic2 Trial http://www2.warwick.ac.uk/fac/med/research/hscience/ctu/trials/critical/paramedic2/caa/

ALP Trial • Amiodorone vs. • Lidocaine vs. • Placebo

• Resuscitation Outcome Consortium (ROC) study group

• Out of hospital v-fib arrest

• Enrolled last patient 10/24/15

• Goal is drug administration < 10 minutes after arrival on scene

• Goal: 3,000 patients

• Multi-city EMS trial

And the winner is…. A. Amiodarone B. Lidocaine C. Both are beneficial D. Neither Kudenchuk et al. (2016) NEJM

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2015 Medications Levels of Evidence – ILCOR/AHA Recommendation

Class LOE

Standard dose Epinephrine (1 mg q 3 -5 min) may be reasonable

IIb

B-R

High dose Epinephrine is not recommended (No benefit)

III

Vasopressin has no advantage as a substitute (Removed)

IIb

Amiodorone may be considered for Vf/pVT unresponsive to CPR, defib and vasopressor therapy

IIb

B-R

Lidocaine may be considered as an alternative to Amiodarone

IIb

B-R

Magnesium for VF/pVT is not recommended (No benefit)

III

It is reasonable to establish IO access if IV access is not readily available (from 2010)

IIa

B-R

C

Post Cardiac Arrest: Targeted Temperature Management

Post-Arrest Optimal Temperature?

33˚C vs. 36˚C

Nielsen et al (2013) NEJM

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Clinical assessment: • Does mild hypothermia (32 - 34˚C) reduce mortality & improve neurologic outcomes post cardiac arrest? • YES!!!!

37˚ C

• Does 36˚ C have the same benefit? • YES!!!

36˚ C 34˚ C

• Does “normothermia” have the same benefit? • We don’t know!!!

32˚ C

• Is fever bad post-cardiac arrest? • YES!!!

2015 Targeted Temperature Management Levels of Evidence – ILCOR/AHA Recommendation

Class LOE

Recommend against routine pre-hospital cooling of patients with ROSC with rapid infusion of cold IV fluids – No Harm

III

A

Comatose adult patients with ROSC after CA should have Targeted Temperature Management. For Vfib/pVT OHCA: For non Vfib/pVT & IHCA:

I I

B-R C-EO

Maintain temperature 32 - 36˚ C

I

CB-R

TTM for a minimum of 24 hours after achieving ROSC

IIa

C-EO

It may be reasonable to actively prevent fever in comatose patients after TTM

IIb

C-LD

In conclusion, • Resuscitation involves a system of care, all being inter-dependent on improving outcomes • We need to focus on high quality CPR & early defibrillation • Capnography & CPR feedback devices should be considered to monitor quality • Temperature should be managed to 32 - 36˚ C in patients resuscitated from cardiac arrest

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