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

The 2015 BLS & ACLS Guidelines:What’s New?National Teaching InstituteNew Orleans, LANicole Kupchik RN, MN, CCNS, CCRN, PCCN, CMCIndependent CNS/Staff NurseObjectives Discuss the updates to the 2015 guidelines. Describe the importance of HIGH quality CPRincluding proper rate, depth, minimizing pauses& optimal chest compression fraction. Discuss the recommendations for medications.2015 ACLS/BLS hp/american-heartassociation/1

2015 RecommendationsAHA RecommendationsClass 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 QualityWhat constitutes HIGH quality CPR? Chest compression rate 100 – 120 / minDepth 2 – 2.4 inchesFull recoil of the chestMinimizing 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 minuteCirculation 2015, AHA BLS/ACLS Guidelines2

Chest Compression Fraction The % of time spent providing compressionswhile the patient is pulseless May also be called “compression ratio” Goal: At least 80%!Is it acceptable to be off thechest for 20% of an arrest?PositioningLeaning & recoil – 5’9”? Use a stepstool!2015 CPR QualityLevels of Evidence – ILCOR/AHARecommendationClass LOEChest Compression Rate 100 – 120 / minuteIIaChest Compression Depth 2”- 2.4”IC-LDChest Compression Fraction 60%IIbC-LDMinimizing Pre & Post-shock pausesIC-LDAllowing full recoil of the chest wallIIaC-LDImpedance threshold devices – NOTrecommendedIIIArtifact altering algorithms – InsufficientevidenceIIbC-LDC-EO3

Minute by minute breakdownMechanical Chest CompressionDevices Provides effective, consistent and uninterruptedcompressions during: Intra-departmental transportDefibrillationAdvanced proceduresCardiac CatheterizationLong casesLimited resources2015 Feedback & Mechanical DevicesLevels of Evidence – ILCOR/AHARecommendationClass LOEUsing feedback devices to guide compression qualityIIbB-RThe use of mechanical compression devices may bea reasonable for use by properly trained personnel.The use of mechanical compression devices may be IIbconsidered in specific settings where the delivery of highquality manual compressions may be challenging ordangerous to the provider.C-EOECPR – Venous/Arterial ECMO may be considered forrefractory cardiac arrest when the cause is likelyreversibleC-LDIIb4

AVOID Over-ventilation!!! If patient does not have an advanced airway:30:2“HyperventilationDo you stop compressions for ventilations? YESKills” If the patient has an advanced airway:10 breaths / min(1 breath every 6 seconds)-ECCU Conference 2015Do you stop compressions for ventilations? NO-2015 BLS/ACLS Guidelines2015 CapnographyLevels of Evidence – ILCOR/AHARecommendationClass LOEContinuous Waveform Capnography to verify ETT placementIC-LDLow PEtCO2 ( 10 mmHg) after 20 minutes in intubatedpatients is strongly associated with failure of resuscitationIIbC-LDShould not be used in isolation or in non-intubated patients asa marker to terminate resuscitationIIICapnography as a measure of CPR qualityCapnography as an indicator of ROSC5

DefibrillationVentricular fibrillation Most successful treatment for v-fib is defibrillation! For every minute delay, survival decreases by10%!!!Metoba et al (2010) CirculationN 13, 053The 2nd most cited paper in Resuscitationin the 5-year period after it waspublished!Conclusion:Pause duration does affectVF termination rate.6

Pauses are bad. Very bad. OHCA, observational study Evaluated pauses in allrhythms including PEA &asystole Survival decreased 11% per 5second increase in durationof longest overall pause Individual long pauses maybe more harmful thanmultiple short pauses even ifthe overall CCF is similarBrouwer, Walker, Chapman, Koster (2015) Circulation 132:1030-37.Compressions37 sec non-shock pauseCompressions20217

2015 DefibrillationLevels of Evidence – ILCOR/AHARecommendationClass LOEFor manual defibrillators, we suggest that pre & postshock pauses are as short as possible.IC-LDImmediately resume chest compressions after shockdelivery in adults in cardiac arrest in any settingIIbC-LDDefibrillators with bi-phasic waveforms are preferredto monophasic for treatment of atrial or ventriculararrhythmiasIIaB-RUse manufacturer's recommended energy dosingIIbC-LDSingle shock strategy is suggested (vs. stacked)IIaB-NRDrugsStudies 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) NEJMHerlitz et al (1995) Resuscitation*Paradis et al (1991) JAMA*Epi associated with worse outcomes8

Is Epinephrine beneficial or doesit cause harm? Current recommendation: 1 mg Q 3 – 5 min RCT Epi vs. PlaceboWarwick UniversityUK & WalesEnrollment started Sept 20148,000 subjectsOut-of-Hospital Cardiac Arrest Paramedic2 cience/ctu/trials/critical/paramedic2/caa/ALP Trial Amiodorone vs. Lidocaine vs. Placebo Resuscitation OutcomeConsortium (ROC) studygroup Out of hospital v-fibarrest Enrolled last patient10/24/15 Goal is drugadministration 10minutes after arrival onscene Goal: 3,000 patients Multi-city EMS trialAnd the winner is .A. AmiodaroneB. LidocaineC. Both are beneficialD. NeitherKudenchuk et al. (2016) NEJM9

2015 MedicationsLevels of Evidence – ILCOR/AHARecommendationClass LOEStandard dose Epinephrine (1 mg q 3 -5 min) may bereasonableIIbB-RHigh dose Epinephrine is not recommended (No benefit)IIIVasopressin has no advantage as a substitute (Removed)IIbAmiodorone may be considered for Vf/pVT unresponsive toCPR, defib and vasopressor therapyIIbB-RLidocaine may be considered as an alternative to AmiodaroneIIbB-RMagnesium for VF/pVT is not recommended (No benefit)IIIIt is reasonable to establish IO access if IV access is not readilyavailable (from 2010)IIaB-RCPost Cardiac Arrest:Targeted TemperatureManagementPost-Arrest Optimal Temperature?33 C vs. 36 CNielsen et al (2013) NEJM10

Clinical assessment: Does mild hypothermia (32 - 34 C)reduce mortality & improve neurologicoutcomes post cardiac arrest? YES!!!!37 C Does 36 C have the same benefit? YES!!!36 C34 C Does “normothermia” have the samebenefit? We don’t know!!!32 C Is fever bad post-cardiac arrest? YES!!!2015 Targeted TemperatureManagementLevels of Evidence – ILCOR/AHARecommendationClass LOERecommend against routine pre-hospital cooling of patientswith ROSC with rapid infusion of cold IV fluids – No HarmIIIAComatose adult patients with ROSC after CA should haveTargeted Temperature Management.For Vfib/pVT OHCA:For non Vfib/pVT & IHCA:IIB-RC-EOMaintain temperature 32 - 36 CICB-RTTM for a minimum of 24 hours after achieving ROSCIIaC-EOIt may be reasonable to actively prevent fever in comatosepatients after TTMIIbC-LDIn conclusion, Resuscitation involves a system of care, all beinginter-dependent on improving outcomes We need to focus on high quality CPR & earlydefibrillation Capnography & CPR feedback devices should beconsidered to monitor quality Temperature should be managed to 32 - 36 C inpatients resuscitated from cardiac arrest11

-2015 BLS/ACLS Guidelines “Hyperventilation Kills”-ECCU Conference 2015 2015 Capnography Levels of Evidence – ILCOR/AHA Recommendation Class LOE Continuous Waveform Capnography to verify ETT placement I C-LD Capnography as a measure of CPR quality Capnography as an indicator of ROS