New Practices in ACLS Rapid Fire Jason Persoff, MD Assistant Professor of Hospital Internal Medicine Mayo Clinic Jacksonville

Evidence-Based Rapid Fire o What new changes to BLS should I be implementing in the hospital setting? o What new recommendations related to medications provided during ACLS do I need to know? o Should family members be present during a code?

ACLS Medications

o Antiarrhythmics o Increase QTc o Increase risk of cardiac arrest o Do antiarrhythmics promote survival in IHCA? o Bloom: amiodarone improves survival o Most others: survival to hospital discharge is lower o Bloom et al. Am J Heart 2007 o Pollak et al. Can J Card 2006 o VanWalraven et al. Ann Emerg Med 1998

ACLS Medications o Medications that have shown survival o Beta Blockers o ACEI o Bloom et al. Am J Heart 2007 o Vasopressin o Pediatrics: survival improved o Adults: seen in higher proportion of non-survivors o Stiell et al. Lancet 2001 o DeMos et al. Crit Care Med 2006 o VanWalraven et al. Ann Emerg Med 1998

ACLS Medications o Calcium o Administration occurs higher in non-survivors o Bicarbonate o Higher rates of death in IHCA o Atropine o Higher rates of death in IHCA o Magnesium o No changes in survival in any subgroup o VanWalraven et al. Ann Emerg Med 1998 o DeMos et al. Crit Care Med 2006 o Thel et al. Lancet 1997

ACLS Medications

Shockable Rhythm? Yep V-Fib Pulseless VT Have no idea Nope PEA Asystole 360J Mono 150J Biphasic 150J Biphasic or 5 Cycles (150 Compressions) Shock Drug Shock Pressor (Vasopressin or Epi) Antiarrhythmic (Amiodarone)

Family Presence on a CODE o Nursing staff believe families should be present on codes (>75%) o Kuzin et al. Pediatrics Oct;120(4):e o Best review: Critchell and Marik o Am J of Hospice Pall Med 2007

2008: The Revolution Begins o Bardy, et al. Home use of automated external defibrillators for sudden cardiac arrest. NEJM 2008; 358: Online only at April 1, 2008http:// o Sayre, et al. Hands only (compression-only) CPR. Circulation 2008; 117: Online only at April 1, o Peberdy, et al. Survival from in-hospital cardiac arrest during nights and weekends. JAMA 2008; 299: o Chan, et al. Delayed time to defibrillation after in- hospital cardiac arrest. NEJM 2008; 358: 9-17.

Epidemiology o 88% of inpatient cardiac arrest (IHCA) occurs in patients with DNR orders o 12% undergo resuscitation o per 1000 admissions o Most occur in ICU (45%) o Few arrests are unwitnessed (12%) o Sandroni et al. Resuscitation 2004.

Epidemiology Demographics of 37,782 inpatient cardiac arrests Nadkarni et al., JAMA 2006; 295 Age (y) ± SD (age range)65.3 ± 15.2 (18-111) Male Gender57% Caucasian Black Hispanic Other 67% 20% 5% 8% Medical (Cardiac) Medical (Non-Cardiac) Surgical (Cardiac) Surgical (Non-cardiac) Trauma 18% 46% 17% 7% 10%

Prognosis o Terminology o ROSC (Return of spontaneous circulation) o SHD (Survival to hospital discharge) o NIS (Neurologically intact survival)—CPC 0 or 1 o NIS o Cerebral Performance Category (CPC) o 0 Normal o 1 Good o 2 Moderate disability (Caffeinated) o 3 Major disability o 4 Persistent vegetative state, coma o 5 Brain death o 6 Me post-call

Prognosis o Pure respiratory events o SHD (reference) OR 1.0 o Vs. VF/VT Arrest: OR 4.2 ( ) o Vs. Asystole/PEA Arrest: OR 21.0 ( ) o Brindley et al. CMAJ 2002.

Prognosis o Ventricular Fibrillation/Tachycardia o ROSC 54-76% o SHD % o NIS 58-75% o PEA/Asystole Arrests o ROSC 43-52% o SHD 10-20% o NIS 61-62%

Prognosis o Discrepancies o Men are twice as likely to have VF than women o Herlitz et al. Resuscitation o Women are more likely to survive (OR 1.66, ) o Herlitz et al. Resuscitation o Blacks have a lower likelihood of SHD o Ebell et al. J Fam Prac o Blacks had statistically robust delays in defibrillation o Chan et al. NEJM 2008.

Prognosis o “It’s a good time to die.”—Some action movie o 1500 “Golden Hour” o Bad time of day: nighttime o Survival lowest o Brindley et al. CMAJ o Nocturnal arrest has half the likelihood of SHD o Herlitz et al. Resuscitation o More likely due to asystole/PEA o Peberdy et al. JAMA 2008.

Prognosis o Nocturnal IHCA o Less likely to have ROSC (44.7% vs. 51.1%) o Less likely to survive 24 hours (28.9% vs. 35.4%) o Less likely to SHD (14.7% vs. 19.8%) o Weekend o Commensurate to nocturnal survival

Basic Life Support o CPR when done perfectly provides only… o 1/3 normal cardiac output o 10-15% normal cerebral blood flow o 1-5% normal cardiac blood flow o Sanders et al o Goals o Push hard o Pump fast o Good recoil o How many push ups can you do? o Rotate rescuers

Basic Life Support o In swine… o Rapid compressions: o 80/min 10% survival at 24 hrs o 100/min 100% survival at 24 hrs o Yu et al o Continuous vs. Classic o Better coronary perfusion pressures o Higher “neurologically normal” function o Kern et al. 2002

Basic Life Support o Compressions too shallow 62.6% of the time o Compressions too slow 71.9% of the time o Abella et al o CPR Good: Survival at 14d: 16% o CPR Bad: Survival at 14d: 4% o VanHoeyweghen et al

Basic Life Support o Delay in chest compressions = death o CPR started < 1 minute after collapse: SHD 34% o CPR started  1 minute after collapse: SHD 14% o Skrifvars et al. Resuscitation 2006 o Code team arrival delay of >2 minutes after arrest: SHD begins to decrease o Code team arrival >6 minutes after arrest: SHD 0% o Sandroni et al. Resuscitation 2004

Basic Life Support o What is the appropriate tidal volume for a patient in cardiopulmonary arrest? o 10cc/kg, or roughly 750cc o What is the volume of an adult bag-valve-mask? o 1.5 liters o Designed for 1-handed operation o ETT is misplaced 6-14% of the time o Katz et al. Ann Int Med o “Iatrogenic hypotension” o Over-zealous BVM use due to o Desire to correct hypoxia o Belief that hyperventilation will correct acid-base derangements

Basic Life Support o Rate exceeded at least 60.9% of the time in humans o In swine models, hyperventilation resulted in… o …increased intrathoracic pressure o …decreased coronary perfusion pressures o …lower survival o Aufderheide, et al

Basic Life Support o Phenomenon of auto-PEEP usually referred to patients on a ventilator

Basic Life Support Michard F. Anesthesiology 2005

Basic Life Support o Current clinical controversy o Should we ventilate at all? o April 1, 2008 o No…compressions only in layperson resuscitation o Most animal models show NO BENEFIT to ventilations plus ventilations to compressions only o In humans o Equivalent SHD in typical and compression-only CPR o 1-year NIS similar

Basic Life Support o Striking the balance o No oxygenation without circulation o The longer resuscitation is attempted, the lower the oxygen level o Threshold appears to be 4 minutes into an arrest o Delivery of as little as 2 breaths : 100 compressions after 4 minutes of continuous compressions had better outcomes o Sanders et al. Ann Emerg Med o Interesting aside…Why don’t people do CPR? o Only 1.4% of bystanders feared disease

Conclusions?