1. ACLS 2005 What is new and why? Morbidity Rounds Feb 15, 2006 Rob Hall MD, FRCPC

2. 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

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

4. 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

5. Circulation 2005;112:IV-19-34IV- CPR/BLS

6. 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 8 year (Lay rescuer) adolescent to adult (HCP)

7. 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

8. 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

9. 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

10. ACLS 2000 Compress/ Ventilation ratio Adult/ Adolescent ChildInfant Before advanced airway device 15:25:1 After Advanced Airway Device Placed: 5 compressions to 1 ventilation (synchronized)

11. ACLS 2005 Compress/ Ventilation ratio Adult/ Adolescent ChildInfant Single Layperson 30:2 Double Layperson 30:2 Single HCP30:2 Double HCP30:215:2 After Advanced Airway Device Placed: 100 compression/min 10 breaths per minute (unsynchronized)

12. ACLS 2005 Compress/ Ventilation ratio Adult/ Adolescent ChildInfant Single Layperson 30:2 Double Layperson 30:2 Single HCP30:2 Double HCP30:215:2 After Advanced Airway Device Placed: 100 compression/min 10 breaths per minute (unsynchronized)

13. Circulation 2005;112:IV-19-34IV- Adult BLS Healthcare Provider Algorithm

14. Circulation 2005;112:IV-19-34IV- Electrical Therapies

15. Part 5: Electrical Therapy

16. Truncated Exponential Rectilinear Biphasic = increased ROSC, no increase Survival to hospital discharge

17. Lifepak 12 and 20 are both biphasic (truncated exponential)

18. Recommended Energy for Defibrillation EnergyMonophasicBiphasic Rectilinear Biphasic Truncated Exponential Biphasic Unknown 1 st shock 360J120J150J200J Subsequent shocks 360J= or > 120J = or > 150J = or > 200J Lifepak 12 and 20 Peds: 2 J/kg then 4 J/kg

19. Recommended Energy for Cardioversion for Lifepak 12/20 RhythmEnergy Afib 100-120J Aflutter 50-100J ? PSVT 50-100J ? Vtach 150J ? Polymorphic Vtach 150J

20. Timing of Defibrillation Shock First vs CPR First?

21. 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 FirstPNNT Overall24% 30%.0416 Response < 4min31% 32%.87 Response > 4min17% 27%.007 10

22. 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 FirstPNNT Overall15% 22%.17 Response < 5min29% 23%.61 Response > 5min4% 22%.006 5.5 A priori subgroup analysis

23. 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 Overall5.1% 4.2%.81 (.3-2.6) –Survival to d/c Defib First CPR First P Response < 5min0% 12%.25 Response > 5min4.9% 3.5%.74 Post hoc subgroup analysis

24. 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

25. Part 6: CPR Techniques and Devices “Non-traditional” CPR and devices not universally recommended Recognition of growing evidence “Optional for Health Care Providers” –Active Compression-Decompression CPR –Mechanic pistons –Load Distributing Band CPR/Vest CPR Research –Thoracic-Abdominal Compression-Decompression CPR

26. Circulation 2005;112:IV-19-34IV- ALS

27. Part 7.2: Management of Cardiac Arrest ACLS Pulseless Algorithm 2005 –Vfib Algorithm –PEA Algorithm –Asystole Algorithm

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

29. 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

30. Amiodarone for Vfib/pulseless VT ARREST TRIAL DBRCT, N=504 Amio vs Placebo Survival PL Amio P –Admission 34% 44%.03 –Discharge 13.4% 13.2% NS ALIVE TRIAL DBRCT, N = 347 Amio vs Lidocaine Survival Lido Amio P –Admission 12% 23%.009 –Discharge 3.8% 6.8% NS Kudenchuk et. al. NEJM 1999. 341(12): p.871. Dorian et. al. NEJM 2002. 346(12): p.884.

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

32. 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)

33. 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 AVPEPIP Admission36%31%.06 Discharge10%10%.99 –Survival Asystole AVPEPIP NNT Admission29%20%.02 Discharge4.7%1.5%.04 31 Problem = multiple subgroup analysis (29); suspected type I (alpha) error

34. Circulation 2005;112:IV-19-34IV- ALS Tachy/Brady

35. Circulation 2005;112:IV-67-77IV- Bradycardia Algorithm

36. Bradycardia Notes No major changes Increased emphasis on early pacing for unstable patients Atropine unlikely to work with infranodal blocks/escape rhythms –2 nd degree type II AVB –3 rd degree AVB –Wide QRS escape rhythm

37. 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 …………..

39. Circulation 2005;112:IV-67-77IV- ACLS Tachycardia Algorithm

40. Wide QRS Tachycardia

41. 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

42. Part 7.5: Postresuscitation Should we induced hypothermia post cardiac arrest?

43. Induced Hypothermia: NEJM Feb 2002 --what is the evidence? Austrian Study –RCT, N=136 –Witnessed VF/pulseless VT –Excluded: Sats 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

44. 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

45. Circulation 2005;112:IV-19-34IV- What really matters? CPR/BLS/Defib

46. 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

47. Why the emphasis on CPR and defibrillation? OPALS study –Stiell. NEJM 2004. 351(7). P 647-656. BLS + Rapid Defibrillation Survival to 11%15%p.001 Admission Survival to5.0%5.1%p.83 Discharge ALS care (ETT,iv,drugs)

48. Why the emphasis on CPR and defibrillation? OPALS study –Stiell. NEJM 2004. 351(7). P 647-656. –Logistic Regression OR for survival Witnessed arrest 4.4 Bystander CPR3.7 AED < 8min3.4

49. 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 isn’t CPR taught in high-school?