ACLS 2005

What is new and why?

Morbidity Rounds Feb 15, 2006 Rob Hall MD, FRCPC

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

ACLS 2005 Guidelines

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

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

CPR/BLS

Circulation 2005;112:IV-19-34IV-

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
<1year, 1-8 year, >8 year (Lay rescuer) <1year, 1-adolescent, >adolescent to adult (HCP)

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

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

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

ACLS 2005
Compress/ Ventilation ratio Single Layperson Double Layperson Single HCP Double HCP Adult/ Adolescent 30:2 30:2 30:2 30:2 Child 30:2 30:2 30:2 15:2 Infant 30:2 30:2 30:2 15:2

After Advanced Airway Device Placed: 100 compression/min 10 breaths per minute (unsynchronized)

ACLS 2005
Compress/ Ventilation ratio Single Layperson Double Layperson Single HCP Double HCP Adult/ Adolescent 30:2 30:2 30:2 30:2 Child 30:2 30:2 30:2 15:2 Infant 30:2 30:2 30:2 15:2

After Advanced Airway Device Placed: 100 compression/min 10 breaths per minute (unsynchronized)

Adult BLS Healthcare Provider Algorithm

Circulation 2005;112:IV-19-34IV-

Electrical Therapies

Circulation 2005;112:IV-19-34IV-

Part 5: Electrical Therapy

Defibrillators

Monophasic

Biphasic

Rectilinear

Truncated Exponential

Part 5: Electrical Therapy

Truncated Exponential Rectilinear

Biphasic = increased ROSC, no increase Survival to hospital discharge

Lifepak
12 and 20 are both biphasic (truncated exponential)

Recommended Energy for Defibrillation

Energy Monophasic Biphasic Rectilinear Biphasic Truncated Exponential Biphasic Unknown

1st shock

360J

120J

150J

200J

Subsequent shocks

360J

= or > 120J

= or > 150J

= or > 200J

Peds: 2 J/kg then 4 J/kg

Lifepak 12 and 20

Timing of Defibrillation

Shock First vs CPR First?

Evidence for CPR before defibrillation

Cobb JAMA 1999
Prospective observational trial, N=1117 Pre-intervention = defibrillate ASAP Post-intervention = 90 sec CPR before defib Survival to d/c Defib First CPR First P
Overall Response < 4min Response > 4min 24% 31% 17% 30% 32% 27% .04 .87 .007

NNT
16 10

Evidence for CPR before defibrillation

Wik JAMA 2003
Randomized clinical trial, N=200 Defibrillate ASAP vs CPR X 3 min before defibrillation Survival to d/c Defib First CPR First P NNT
Overall Response < 5min Response > 5min 15% 29% 4% 22% 23% 22% .17 .61 .006

5.5

A priori subgroup analysis

Evidence for CPR before defibrillation

Jacobs. Emerg Med Australasia. Feb 2005.
Randomized clinical trial, N=256 Defibrillate ASAP vs CPR X 90 sec before defibrillation Survival to d/c Defib First CPR First OR 95%CI
Overall 5.1% 4.2% .81 (.3-2.6)

Survival to d/c
Response < 5min Response > 5min

Defib First CPR First P

0% 4.9% 12% 3.5% .25 .74

Post hoc subgroup analysis

Timing of Defibrillation
ACLS 2005 Recommendation
CPR X 5 cycles of 30:2 (about 2 min) recommended for out-of-hospital VF arrest
Response time > 4-5 minutes Unwitnessed

ALS

Circulation 2005;112:IV-19-34IV-

Part 7.2: Management of Cardiac Arrest

ACLS Pulseless Algorithm 2005
Vfib Algorithm PEA Algorithm Asystole Algorithm

Circulation 2005; 112:IV-58-66IV-

Notes on VF and pulseless VT

CPR 30:2 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; 112:IV-58-66IV-

Amiodarone for Vfib/pulseless VT

ARREST TRIAL DBRCT, N=504 Amio vs Placebo
Survival
Admission Discharge

ALIVE TRIAL DBRCT, N = 347 Amio vs Lidocaine

P Survival Lido Amio
Admission Discharge

PL Amio

34% 44% .03 13.4% 13.2% NS

12% 23% .009 3.8% 6.8% NS

Kudenchuk et. al. NEJM 1999. 341(12): p.871.

Dorian et. al. NEJM 2002. 346(12): p.884.

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

Circulation 2005; 112:IV-58-66IV-

Why Vasopressin?
Or why not

Linder. Lancet 1997.

N=40, out of hospital Vfib, vasopressin vs epi Increased survival to admission not discharge

Stiell. Lancet 2001.

N=200, in-hospital Vfib/PEA/asystole Vasopressin vs epi No difference in survival to discharge (power 0.8)

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
Admission Discharge 36% 10% 31% 10%

P
.06 .99

Survival Asystole
Admission Discharge

AVP
29% 4.7%

EPI
20% 1.5%

NNT

.02 .04 31

Problem = multiple subgroup analysis (29); suspected type I (alpha) error

ALS Tachy/Brady

Circulation 2005;112:IV-19-34IV-

Bradycardia Algorithm

Circulation 2005;112:IV-67-77IV-

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

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 ..

ACLS 2005 Approach Tachycardia

STABLE

UNSTABLE Cardiovert

Narrow

Wide

Regular

Irregular

Regular

Irregular

ACLS Tachycardia Algorithm

Circulation 2005;112:IV-67-77IV-

Wide QRS Tachycardia

Stable Wide QRS Regular Irregular

Vtach Regular SVT + aberrancy

Torsades Irregular SVT + abberancy

Amiodarone Cardioversion

Torsades

AFIB + BBB

AFIB + WPW

Adenosine for SVT+a Procaine a 1st line option Lidocaine NOT 1st line Sotalol NOT 1st line

Defibrillate Magnesium Stop Rx, correct lytes, treat ischemia

Treat as per Afib

AVOID AVN blockers Amidarone

Prolonged QTc: Pacing, isoproterenol, Lidocaine

Normal baseline QTc: Amio or Lidocaine

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

Part 7.5: Postresuscitation

Should we induced hypothermia post cardiac arrest?

Induced Hypothermia:
NEJM Feb 2002 --what is the evidence?
Austrian Study
RCT, N=136 Witnessed VF/pulseless VT Excluded: Sats < 85%, hypotension > 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, N=77 Initial VF rhythm then comatose Excluded: SBP<90 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

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

What really matters?

CPR/BLS/Defib

Circulation 2005;112:IV-19-34IV-

Why the emphasis on CPR and defibrillation?

OPALS study
Stiell. NEJM 2004. 351(7). P 647-656.
BLS + Rapid Defibrillation
N = 1391 12 months

ALS care (ETT,iv,drugs)

N = 4247 36 months

Why the emphasis on CPR and defibrillation?

OPALS study
Stiell. NEJM 2004. 351(7). P 647-656.
BLS + Rapid Defibrillation
Survival to Admission Survival to Discharge 11%

ALS care (ETT,iv,drugs)

15% p.001

5.0%

5.1%

p.83

Why the emphasis on CPR and defibrillation?

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

Take home points

One shock (not three) for VF Lower energy with biphasic defibrillators Less emphasis on drugs More emphasis on CPR
CPR 30:2 ratio CPR before defibrillation for response times > 4 minutes Quality CPR with minimal interruptions Should we call ourselves CPR-coaches? Why isnt CPR taught in high-school?