What’s New With The ACLS & BLS Guidelines?

WHAT’S NEW WITH THEACLS & BLS GUIDELINES?HealthTrust Resuscitation Webinar Series

Nicole Kupchik, MN, RN, CCNS, CCRN,PCCN-CMC Clinical Nurse SpecialistFormer Code BlueCommittee ChairCurrently consultantStaff Nurse

4-Part Resuscitation WebinarSeriesOct. 26 – “What’s New With the ACLS & BLSGuidelines?”Nov. 30 – “High Quality CPR & Why It Matters!”Dec. 20 – “Capnography: It’s about more thanventilation!”Feb. 1 – “My Patient was Resuscitated, NowWhat?”

Disclosures Speaker’s Bureau: Physio-Control, Medtronic,Mallinckrodt Consultant: Physio-Control

Objectives Discuss the 2015 ACLS & BLS GuidelinesDescribe the components of high quality CPRDiscuss the evidence behind recommendedmedications

2015 ACLS/BLS hp/american-heartassociation/

Educational manuals available

25%23%45%2%5%

Incidence of cardiac arrestOut-of-hospital (OHCA):In-Hospital (IHCA):2015 – 326,200 45.9% receivedbysta nder CPR 10.6% survival2015 –Incidence estima ted a t209,000

According to the GWTG database, the survivalrate from in-hospital cardiac arrest is:A.B.C.D.8.6%25.5%42.6%58.4%

What is the most common typeof in-hospital cardiac arrest?A.B.C.D.PEA and AsystoleVfib and PEAVtach and VfibAsystole and VfibAsystole and Pulseless Electrical Activity (PEA) makeup 67% of all adult in-hospital cardiac arrestsCirculation (2013); Morrison, et al.

Hospital chain of survival Approximately 80% of IHCA had abnormal vital signsdocumented 8 hours before their arrest More than 50% of cardiac arrests are due to respiratory failure& hypovolemic shock

What can we do to improve? Prevent the arrest! Hospital focus is to respond once the arrest hasoccurredResuscitate those who are resuscitatable!#1#2#3#4#5CPR QualityEarly & effective defibrillationPost-Arrest temperature controlFeedback to teams on performanceMeasure, practice & improve!!!

CPR QUALITY

How long do healthcare providersretain their CPR skills after training?A.B.C.D.E.2 years1 year6 months3 months 3 months

Maintenance of competencySkill Decline in CPR/AED Trainees100%90%80%70%% Pa ssing Skills Test60%50%40%34%27%30%20%10%10%0%Figure 1. Avera ge Skill Loss3 months6 months12 monthThe innovative competency-basedtraining program for high-qualityCPR and improved al/Resuscitation-Quality-Improvement UCM 459324 SubHomePage.jsp

“Poor quality CPR should beconsidereda preventable harm”Meany, Bobrow, Mancini et al (2013) Circulation 128(4):417-4

Compression rate mantra in 2010 “Push fast, push hard”Too SlowToo Fast(Before 2010)(current)100 – 120 /min

Chest Compression Fraction The amount of time spent providingcompressionsMay also be called “chest compression ratio” Goal: As high as possible! Guidelines:at least 60% High performing hospitals & EMS: 80 – 90%Is it acceptable to be off thechest for 40% of an arrest?

ROC Study group; OHCA, survival to dischargeContinuous 2 minutes of compressions without pauses incompressions for breathingvs. Chest compressions with pauses for breathing Enrolled over 23,000 patients in 8 regions across the U.S.& Canada

And the results are A.B.C.30 compressions : 2 ventilations2 minutes continuous compressions withventilations every 6 seconds?The outcomes were the same; no statisticaldifferenceNichol et al (2015). NEJM; 373(23)2203-2214.

2015 CPR QualityLevels of Evidence – ILCOR/AHARecommendationClassLOEChest Compression Rate 100 – 120 / minuteIIaC-LDChest Compression Depth 2”- 2.4”IC-LDChest Compression Fraction should be as high as possible,with a minimum 60%IIbC-LDMinimizing Pre & Post-shock pausesIC-LDAllowing full recoil of the chest wallIIaC-LDNeumar et al (2015). Circulation;132[suppl 2]:S315-S367

CC Rate 141

Minute by minute breakdown

AVOID excessive ventilation!!! If patient does not have an advanced airway:Adults 30:2, Peds 15:2Do you stop compressions for ventilations? YES If the patient has an advanced airway:10 breaths/min(1 breath every 6 seconds)Do you stop compressions for ventilations? NO-2015 BLS/ACLS GuidelinesIssues: Too many breaths, too large a tidal volume

AVOID excessive ventilation!!! If patient does not have an advanced airway:Adults30:2,Peds15:2“HyperventilationDo you stop compressions for ventilations? YES Kills”If the patient has an advanced airway:10 breaths/min(1 breath every 6 seconds)Do you stop compressions for ventilations? NO-ECCU Conference 2015-2015 BLS/ACLS GuidelinesIssues: Too many breaths, too large a tidal volume

Waveform Capnography Attaches to ET tube, measures end tidal CO2Can also be used with a BVM

When to use Waveform Capnography? Gold standard for endotracheal tubeplacement Level 1C-LD recommendationAHA/ILCORTube position - dislodgementProcedural/moderate - deepsedationHigh risk patient on PCA pumpCardiac arrest Quality indicator of compressionsInformation helpful to determinecessation of resuscitation efforts Post arrest – fluid responsiveness

Continuous WaveformCapnography Normal PEtCO2 35 – 45 mmHgCorrelates with PaCO2 in normal V/Qrelationships 5 mmHg differenceIn cardiac arrest - 10 improve CPR quality

2015 Capnography & VentilationLevels of Evidence – ILCOR/AHARecommendationClassLOEContinuous Waveform Capnography to verify ETT placementIC-LDLow PEtCO2 ( 10 mmHg) after 20 minutes in intubated patientsis strongly associated with failure of resuscitationIIbC-LDShould not be used in isolation or in non-intubated patients as amarker to terminate resuscitationIIIVentilation rate 10 breaths per minute with an advanced airwayIIbCapnography as a measure of CPR qualityCapnography as an indicator of ROSCC-LDNeumar et al (2015). Circulation;132[suppl 2]:S315-S367

DEFIBRILLATION

Ventricular fibrillation Most successful treatment for v-fib is defibrillation!For every minute delay, survival decreases by7 - 10% without bystander CPR!!!Metoba et al (2010) CirculationN 13, 053

Pauses are bad. Very bad. OHCA, observational study Evaluated pauses in allrhythms including PEA &asystole Survival decreased 11% per5 second increase induration of longest overallpause 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 pauseCompressions36

37

High Performance Team Clear team leaderUnderstand notonly your role, butthe role of otherson the teamAnticipate whatneeds to happennext

2015 DefibrillationLevels of Evidence – ILCOR/AHARecommendationClassLOEFor manual defibrillators, pre & post shock pauses as short aspossible.IC-LDImmediately resume chest compressions after shock delivery inadults in cardiac arrest in any settingIIbC-LDDefibrillators with bi-phasic waveforms are preferred tomonophasic for treatment of atrial or ventricular arrhythmias .Peds biphasic – 2 J/kg, then 4 J/kg, max 10 J/kgIIaB-RUse manufacturer's recommended energy dosingIIbC-LDSingle shock strategy is suggested (vs. stacked)IIaB-NRNeumar et al (2015). Circulation;132[suppl 2]:S315-S367

MEDICATIONS

Which of the following medications has been shownto increase survival to discharge from rbAmiodaroneNone of the above

Emergency medications – V-fib Epinephrine 1 mg every 3 - 5 min Peds 0.01 mg/kgVasopressin - Removed from CardiacArrest Algorithm!Amiodorone 300 mg, repeat 150 mg Peds– 5mg/kg, repeat up to 2 timesCirculation 2015, AHA ACLS Guidelines

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) NEJMHerlitz et al (1995) Resuscitation*Paradis et al (1991) JAMA*Epi associated with worse outcomes

Is Epinephrine beneficial or does itcause 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 TrialResults in cience/ctu/trials/critical/paramedic2/about/

ALP TrialAmiodorone vs. Lidocaine vs. Placebo Out of hospital v-fib arrestGoal is drug administration 10 minutes after arrivalon scene Resuscitation OutcomeConsortium (ROC) studygroup Multi-city EMS trial Goal: 3,000 patients

And the winner is .A. AmiodaroneB. LidocaineC. Both are beneficialD. NeitherKudenchuk et al. (2016) NEJM

2015 MedicationsLevels of Evidence – ILCOR/AHARecommendationClassLOEStandard dose Epinephrine (1 mg q 3 -5 min) may be reasonableIIbB-RHigh dose Epinephrine is not recommended (No benefit)IIIVasopressin has no advantage as a substitute (Removed)IIbB-RAmiodorone may be considered for Vf/pVT unresponsive to CPR, defiband 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 readily available(from 2010)IIaCNeumar et al (2015). Circulation;132[suppl 2]:S315-S367

In conclusion Thank you for participating in this webinar. Prevent the arrest!Focus on high quality CPR & early defibrillationCapnography should be used to verifyendotracheal tube placementAvoid excessive ventilationStay tuned for updates on medications

Former Code Blue Committee Chair . Discuss the 2015 ACLS & BLS Guidelines . For manual defibrillators, pre & post shock pauses as short as possible. I. C-LD. Immediately resume chest compressions after shockdelivery in adults in cardiac arrest in any setting. IIb.