The New Advanced Cardiac Life Support Guidelines

The New Advanced Cardiac Life Support Guidelines:
Implementing with Precision and Quality!
Robert W. Neumar, MD, PhD

University of Michigan Medical School
Presenter Disclosure Information
Robert W. Neumar, MD, PhD

The New Advanced Cardiac Life Support Guidelines:
Implementing with Precision and Quality!
FINANCIAL DISCLOSURE:
 Research Support: NIH and PhysioControl
UNLABELED/UNAPPROVED USES DISCLOSURE:

 Use of devices for post-cardiac arrest hypothermic targeted
temperature management is not approved by FDA
http://ECCGuidelines.heart.org
New Chains of Survival
2015 ACLS Highlights
• CPR adjuncts
– Impedance threshold device (ITD)
– Active compression-decompression (ACD)
– Mechanical CPR
• CPR pharmacology
– Vasopressors
• Physiologic monitoring during CPR
• Focused ultrasound during CPR
• Extracorporeal CPR (ECPR)
• Post-cardiac arrest coronary angiography and PCI
• Post-cardiac arrest targeted temperature management
• Post-cardiac arrest neuroprognostication
• CPR adjuncts
– Mechanical CPR
– Vasopressors
Impedance Threshold Device (ITD) and
Active Compression Decompression (ACD)
ACD
ITD
Impedance Threshold Device (ITD) and
Active Compression Decompression (ACD)
Survival with Good Neurologic Function (mRS ≤3)
p=0.027
9.0%
8.0%
7.0%
6.0%
5.0%
4.0%
3.0%
2.0%
1.0%
0.0%
Control ITD Control ITD+ACD
Aufderheide NEJM Frascone Resus 2013
2011
2015 AHA ECC
Treatment Recommendations
• The routine use of the ITD as an adjunct during conventional CPR is

not recommended. (Class III: No Benefit, LOE A)
• There is insufficient evidence to recommend for or against the routine

use of ACD-CPR. ACD-CPR may be considered for use when
providers are adequately trained and monitored. (Class IIb, LOE B)
• The combination of ITD + ACD CPR may be a reasonable alternative

to conventional CPR with available equipment and properly trained
personnel. (Class IIb, LOE C-LD)
• CPR adjuncts
– Mechanical CPR
– Vasopressors
Mechanical CPR
Load Distributing Band Mechanical Piston

Mechanical CPR
Survival with Good Neurologic Function (mRS ≤3 or CPC 1-2)
10.0%
8.0%
6.0%
4.0%
2.0%
0.0%
Hallstrom Wik Rubertsson Perkins

JAMA Resus JAMA Lancet
2006 2014 2014 2015
2015 AHA ECC
Treatment Recommendations
• Manual chest compressions remain the standard of care for the

treatment of cardiac arrest, but mechanical piston and load distributing
band devices may be a reasonable alternative for use by properly trained
personnel. (Class IIb, LOE B-R)
• The use of mechanical piston or load distributing band devices may be

considered in specific settings where the delivery of high-quality manual
compressions may be challenging or dangerous for the provider (eg,
limited rescuers available, prolonged CPR, during hypothermic cardiac
arrest, in a moving ambulance, in the angiography suite, during
preparation for extracorporeal CPR [ECPR]), provided that rescuers
strictly limit interruptions in CPR during deployment and removal of the
devices. (Class IIb, LOE C-EO)
• CPR adjuncts
– Mechanical CPR
– Vasopressors
Standard-Dose Epinephrine
Jacobs
Resus
2011
Study not adequately powered

High-Dose Epinephrine
Gueugniaud PY. NEJM 1998

Time to First Epinephrine Dose
Donnino BMJ 2015

2015 AHA ECC
Treatment Recommendation
• Standard dose epinephrine (one mg every 3 to 5

minutes) may be reasonable for patients in cardiac arrest
(Class IIb, LOE B-R).
• High dose epinephrine is not recommended for routine
use in cardiac arrest (Class III: No Benefit, LOE B-R).
• It may be reasonable to administer epinephrine as soon
as feasible after the onset of cardiac arrest due to an
initial nonshockable rhythm (Class IIb, LOE C-LD).
2015 AHA ECC
• Vasopressin offers no advantage as a substitute for

epinephrine in cardiac arrest (Class IIb, LOE B-R).
• The removal of vasopressin has been noted in the Adult
Cardiac Arrest Algorithm―2015 Update.
• Vasopressin in combination with epinephrine offers no
advantage as a substitute for SDE in cardiac arrest
(Class IIb, LOE B-R).
• CPR adjuncts
– Mechanical CPR
– Vasopressors
Physiologic Monitoring During CPR
• Although no clinical study has examined whether titrating

resuscitative efforts to physiologic parameters during
CPR improves outcome, it may be reasonable to use
physiologic parameters (quantitative waveform
capnography, arterial relaxation diastolic pressure,
arterial pressure monitoring, and central venous oxygen
saturation) when feasible to monitor and optimize CPR
quality, guide vasopressor therapy, and detect ROSC
(Class IIb, LOE C-EO).
End-Tidal CO2
Prognostication during CPR
Levine NEJM 1998

End-Tidal CO2
Prognostication during CPR
• In intubated patients, failure to achieve an ETCO2 of greater

than 10 mm Hg by waveform capnography after 20 minutes of
CPR may be considered as one component of a multimodal
approach to decide when to end resuscitative efforts, but it
should not be used in isolation (Class IIb, LOE C-LD).
• The above recommendation is made with respect to ETCO2 in
patients who are with endotracheal intubation.
• In nonintubated patients, a specific ETCO2 cutoff value at any
time during CPR should not be used as an indication to end
resuscitative efforts (Class III: Harm, LOE C-EO).
• CPR adjuncts
– Mechanical CPR
– Vasopressors
Cardiac Ultrasound During
Cardiac Arrest
Hernandez
Resuscitation
2008
Ultrasound
Guided
Resuscitation
Strategy
Hernandez
Resuscitation
2008
2015 AHA ECC
• Ultrasound (cardiac or noncardiac) may be considered

during the management of cardiac arrest, although its
usefulness has not been well established (Class IIb, LOE
C-EO).
• If a qualified sonographer is present and use of
ultrasound does not interfere with the standard cardiac
arrest treatment protocol, then ultrasound may be
considered as an adjunct to standard patient evaluation
(Class IIb, LOE C-EO).
• CPR adjuncts
– Mechanical CPR
– Vasopressors
Extracorporeal Cardiopulmonary
Resuscitation (ECPR)
Percutaneous veno-arterial
extracorporeal membrane
oxygenation (VA-ECMO) during
cardiac arrest
Extracorporeal Cardiopulmonary
Resuscitation (ECPR)
2015 AHA ECC
• There is insufficient evidence to recommend the routine

use of ECPR for patients with cardiac arrest.
• In settings where it can be rapidly implemented, ECPR
may be considered for select patients for whom the
suspected etiology of the cardiac arrest is potentially
reversible during a limited period of mechanical
cardiorespiratory support. (Class IIb, LOE C-LD)
• CPR adjuncts
– Mechanical CPR
– Vasopressors
2015 AHA ECC
• Coronary angiography should be performed emergently

(rather than later in the hospital stay or not at all) for
OHCA patients with suspected cardiac etiology of arrest
and ST elevation on ECG (Class I, LOE B-NR).
• Consistent with all other STEMI care
• Neurological outcomes are unknowable at time of decision
• Many observational studies showing high rates of good

outcome after PCI, and association of successful PCI with
better outcomes
Post-Cardiac Arrest NSTEMI
Non ST Elevation
Kern 2012 JACC

Post-Cardiac Arrest NSTEMI
Dumas,
Cardiovasc
Interv,
2010
Successful PCI Associated With Improved Post-
Cardiac Arrest Outcome With or Without STEMI
Dumas,
Cardiovasc
Interv,
2010
2015 AHA ECC Treatment
Recommendation
• Emergency coronary angiography is reasonable for select

(eg, electrically or hemodynamically unstable) adult patients
who are comatose after OHCA of suspected cardiac origin
but without ST elevation on ECG (Class IIa, LOE B-NR).
• Coronary angiography is reasonable in post–cardiac arrest
patients for whom coronary angiography is indicated
regardless of whether the patient is comatose or awake
(Class IIa, LOE C-LD).
• CPR adjuncts
– Mechanical CPR
– Vasopressors
Optimizing Therapeutic
Hypothermia
• How cold?
• How soon?
• How long?
• Rewarming rate?
Optimizing Therapeutic
Hypothermia
• How cold?
• How soon?
• How long?
• Rewarming rate?
What is the optimal target temperature?
• Out-of-hospital cardiac arrest of presumed cardiac etiology

• All initial rhythms except asystole if unwitnessed
• Comatose with ROSC for at least 20 minutes.
• Prospectively randomized to 33 or 36 °C x 28 hours
• Primary outcome: All cause mortality at end of trial
• 939 total patients
Nielsen NEJM 2013

TTM Trial Temperature Curves
Nielsen NEJM 2013
No Difference in Outcomes with Target
Temperature of 33°C vs. 36°C
Nielsen NEJM 2013
No Difference in Outcomes with Target
Temperature of 33°C vs. 36°C
Nielsen NEJM 2013

How Soon Should Cooling be Started?
Kim, JAMA 2014
• Out-of-hospital cardiac arrest

• All presenting rhythms
• Comatose with ROSC for at least 20 minutes.
• Prospectively randomized to receive 2 L 4°C IV saline in ambulance vs.
standard therapy
• Primary outcome: Survival and neurologic status at hospital discharge
• 1359 total patients
Pre-Hospital Initiation of Cooling using Cold
IV Saline Does Not Improve Outcomes
Kim, JAMA 2014
Increased Complications With Pre-Hospital
Initiation of Cooling using Cold IV Saline
Kim, JAMA 2014
2015 AHA ECC
• TTM recommended for all patients (ie VF/PEA/Asytole/IHCA/OOHCA)

who remain comatose following ROSC from cardiac arrest (Class I, LOE
B-R for VF/VT OHCA; Class I, LOE C-EO for non-VF/VT)
• TTM: select, maintain (for at least 24 hours) constant temperature

between 32°C and 36°C. (Class I, LOE B-R)
• If patient still comatose: continue TTM beyond 24 hours by actively

preventing fever. (Class IIa, LOE C-EO)
• Routine prehospital cooling of patients with rapid infusion of cold IV

fluids is not recommended (no benefit, possible complications). (Class III:
No Benefit, LOE A)
• CPR adjuncts
– Mechanical CPR
– Vasopressors
2015 AHA ECC Treatment
Recommendation
• The earliest time to prognosticate a poor neurologic outcome

using clinical examination in patients not treated with TTM is 72
hours after cardiac arrest (Class I, LOE B-NR).
– Can be even longer than 72 hours after cardiac arrest if the

residual effect of sedation or paralysis confounds the clinical
examination (Class IIa, LOE C-LD).
• The earliest time for prognostication using clinical examination in

patients treated with TTM, where sedation or paralysis could be a
confounder, may be 72 hours after return to normothermia (Class
IIb, LOE C-EO).
Summary
• ITD alone not recommended but ITD+ACD CPR may improve outcomes
• Mechanical CPR not superior to manual CPR
• Epinephrine unchanged and vasopressin removed from algorithm
• Prospectively validated physiologic goals are needed for goal-directed CPR
• End Tidal CO2 <10 mmHg after 20 min of CPR indicator of futility
• Potential role for focused ultrasound, but remains unproven
• Growing evidence supporting ECPR but clinical trials are needed
• Early post-arrest coronary angiography and PCI (if indicate) recommended for
STEMI and NSTEMI.
• Widened therapeutic range for hypothermic TTM and pre-hospital cooling with
cold IV saline not recommended
• Reliability of early neuroprognostication remains limited

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The New Advanced Cardiac Life Support Guidelines:

Implementing with Precision and Quality!

Robert W. Neumar, MD, PhD

Robert W. Neumar, MD, PhD

UNLABELED/UNAPPROVED USES DISCLOSURE:

• The routine use of the ITD as an adjunct during conventional CPR is

• There is insufficient evidence to recommend for or against the routine

• The combination of ITD + ACD CPR may be a reasonable alternative

Load Distributing Band Mechanical Piston

Hallstrom Wik Rubertsson Perkins

• Manual chest compressions remain the standard of care for the

• The use of mechanical piston or load distributing band devices may be

Study not adequately powered

Gueugniaud PY. NEJM 1998

Donnino BMJ 2015

• Standard dose epinephrine (one mg every 3 to 5

• Vasopressin offers no advantage as a substitute for

• Although no clinical study has examined whether titrating

Levine NEJM 1998

• In intubated patients, failure to achieve an ETCO2 of greater

• Ultrasound (cardiac or noncardiac) may be considered

• There is insufficient evidence to recommend the routine

• Coronary angiography should be performed emergently

• Neurological outcomes are unknowable at time of decision

• Many observational studies showing high rates of good

Kern 2012 JACC

• Emergency coronary angiography is reasonable for select

• Out-of-hospital cardiac arrest of presumed cardiac etiology

Nielsen NEJM 2013

Nielsen NEJM 2013

Kim, JAMA 2014

• Out-of-hospital cardiac arrest

• TTM recommended for all patients (ie VF/PEA/Asytole/IHCA/OOHCA)

• TTM: select, maintain (for at least 24 hours) constant temperature

• If patient still comatose: continue TTM beyond 24 hours by actively

• Routine prehospital cooling of patients with rapid infusion of cold IV

• The earliest time to prognosticate a poor neurologic outcome

– Can be even longer than 72 hours after cardiac arrest if the

• The earliest time for prognostication using clinical examination in

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