2015 AHA GUIDELINES UPDATE FOR CPR

AND ECC - HIGHLIGHTS

Steve Lin, MD, MSc, FRCPC

Emergency Physician, Trauma Team Leader, St. Michael's Hospital
Scientist, Rescu, Li Ka Shing Knowledge Institute
Assistant Professor, Department of Medicine, University of Toronto
SPEAKER DISCLOSURES

• No financial conflicts

• Evidence Reviewer for ILCOR

• Chapter Author for 2015 AHA Guidelines for

CPR and ECC
INTERNATIONAL EVIDENCE
EVALUATION AND COUNCIL
GUIDELINES
ACHIEVING CONSENSUS REGARDING
RESUSCITATION SCIENCE
The American Heart Association and other member
councils of International Liaison Committee on
Resuscitation (ILCOR) complete a review of
resuscitation science every five years.

Australian
Resuscitation
Council
AHA EVIDENCE CLASSIFICATION: 2015
AHA RECOMMENDATION
CLASSIFICATION: NEW CLASS III
KEY NEW AND UPDATED
RECOMMENDATIONS:
SYSTEMS OF CARE
UNIVERSAL TAXONOMY FOR SYSTEMS
OF CARE: NEW
NEW AHA ADULT CHAINS OF SURVIVAL

IN-HOSPITAL
(note new
Surveillance and
Prevention link)

OUT-OF-HOSPITAL,
Including EMS
SOCIAL MEDIA TO SUMMON RESCUERS?

Recommendation:
• It may be reasonable to
incorporate social media
technologies to summon
rescuers in close proximity
to a victim.

Why?
• Low evidence, but low
harm and potential benefit,
municipalities could
consider incorporating into
their system.
Screen shot from San Ramon Fire Department website:
http://mobile.firedepartment.org/?rev=0?reload
EARLY WARNING/RAPID RESPONSE
SYSTEMS
• May reduce incidence of cardiac
arrest, particularly on general care
wards
KEY NEW AND UPDATED
RECOMMENDATIONS:
ADULT BLS
DISPATCHER IDENTIFICATION OF
AGONAL GASPS: UPDATED
Recommendation:
• Dispatchers should be trained
to identify agonal gasps and
other presentations of cardiac
arrest
• Allows for immediate
dispatcher-guided CPR

Why?
• Dispatchers should be trained to
recognize agonal gasping
CHEST COMPRESSION RATE: UPDATED

Recommendation:
• Compression rate: 100-120/minute.
–2010 recommendation:
Compression rate at least 100/min.
Why?
• Absolute number of compressions
delivered per minute linked with
survival.
• Actual compression rate is often well
below 100/minute.
• Rates below 100/min or above 120/min
adversely affect outcomes.
ADULT CHEST COMPRESSION DEPTH:
UPDATED
Recommendation:
•Compress at least 2 inches (5cm) for
average adult
• Avoiding excessive compression depth
(greater than 2.4 inches [6cm])
–2010 recommendation was at
least 2 inches
Why?
• In one study of 170 patients
(Hellevuo et al, Resuscitation, 2013)
injuries occurred with depths greater
than 2.4 inches (6cm).
Note:
• Difficult to judge depth without CPR feedback
devices
• Rescuers often do not “push hard” enough
CHEST COMPRESSIONS ARE CRITICAL

Without effective chest compressions:

• Oxygen flow to brain stops.

• Oxygen flow to heart stops.
• Drugs go nowhere.
BYSTANDER NALOXONE FOR OPIOID
OVERDOSE: NEW

Recommendation:
• In additional to
standard BLS care,
trained lay rescuers
and BLS providers may
use
IM or IN Naloxone for
life-threatening
emergency with
suspected opioid
overdose.
BLS SEQUENCES FOR CPR

• Allow for ubiquitous mobile phones

(rescuers can remain with victim and
activate emergency response system)
• Mobile phone should be placed
beside victim on “speaker” so
dispatcher can guide rescuer in CPR
• Enable Health Care Provider to tailor
activation to clinical setting (but no
later than when cardiac arrest
identified)
HEALTHCARE PROVIDER ADULT BLS
SEQUENCE: UPDATED
•Verify scene safety
•Recognize unresponsive adult
•Simultaneously check no breathing /no
normal breathing (ie, agonal gasps) and
check for pulse (10 sec or less)
•Activate emergency response, retrieve
AED (or send someone to do this)
•If no breathing and no pulse, begin sets of
30 chest compressions: 2 breaths
• Use AED as soon as available
G2015 BLS ALGORITHM—PART 1 OF 2
G2015 BLS ALGORITHM—PART 2 OF 2
SUMMARY OF HIGH-QUALITY CPR
COMPONENTS FOR BLS PROVIDERS
SUMMARY OF HIGH-QUALITY CPR
COMPONENTS FOR BLS PROVIDERS—PART 2
DELAYED VENTILATION BY SOME EMS
PROVIDERS
Recommendation:
• For witnessed OHCA with a shockable rhythm, EMS
systems with priority-based multi-tiered response may
use a strategy of up to 3 cycles of 200 continuous
compressions with passive oxygen insufflation and
airway adjuncts.

Why?
• Delaying PPV for victims with witnessed arrest and
shockable shown to be effective in these systems.
• In studies cited, providers received additional training
with emphasis on high-quality compressions.
VENTILATION DURING CPR WITH AN
ADVANCED AIRWAY: UPDATED
Recommendation:
• May be reasonable to deliver 1
breath every 6 seconds (10
breaths/min) while continuous
chest compressions are being
performed (adult and peds).

Why?
• Simplified from range of 1
breath every 6-8 seconds (8-10
breaths/min).
• Should be easier to learn,
remember, and perform.
TEAM RESUSCITATION:
BASIC PRINCIPLES: NEW
Recommendation:
• Increased flexibility for
modifications in BLS algorithm
when appropriate.

Why:
• Algorithms have been
presented as a sequence to
prioritize actions; certain
factors may require localized
modifications.
KEY NEW AND UPDATED
RECOMMENDATIONS:
ACLS
VASOPRESSORS IN CARDIAC ARREST

Recommendations:
• Vasopressin + epinephrine offers no advantage over standard
dose epinephrine—vasopressin deleted from ACLS Cardiac
Arrest algorithm.
• It may be reasonable to administer epinephrine as soon as
feasible after the onset of cardiac arrest with initial
nonshockable rhythm
Why?
• No benefit from addition of vasopressin vs epinephrine alone.
• Very large observational study found association of better
outcome (increased ROSC, survival to hospital discharge, and
neurologically intact survival) with early vs later epinephrine
administration.
LOW ETCO2 ONE ELEMENT PREDICTING
FAILED RESUCITATION?
Recommendation:
• In intubated patients, failure to achieve an ETCO2
greater than 10 mm Hg by waveform capnography
after 20 minutes of CPR may be considered one
component of a multimodal approach to decide
when to end resuscitative efforts but should not be
used in isolation
• Efforts should be made to optimize CPR quality

Why?
• Failure to achieve an ETCO2 greater than 10 mm
Hg after 20 minutes associated with poor outcome
• Low ETCO2 likely indicates very low cardiac output
and pulmonary blood flow during CPR
POST-CARDIAC ARREST DRUG
THERAPY: NEW
Lidocaine
• Inadequate evidence to support the
routine use of lidocaine after cardiac
arrest. It may be considered
immediately after ROSC from cardiac
arrest due to VF/pVT.

β-Blockers
• Inadequate evidence to support the
routine use of a β-blocker after
cardiac arrest. However, the initiation
or continuation of an oral or IV β-
blocker may be considered early
after hospitalization from cardiac
arrest dueto VF/pVT.
 KEY NEW AND UPDATED
RECOMMENDATIONS:
POST-CARDIAC ARREST CARE
POST-CARDIAC ARREST ELEMENTS OF
CARE: UPDATED
• Emergent coronary angiography:
• Should be performed for OHCA patients with suspected cardiac etiology and
ST elevation on ECG.
• May be reasonable for patients who are comatose after OHCA with a
cardiac etiology and no ST elevation.
• Reasonable post-arrest where indicated, whether comatose or awake.

• Targeted temperature management

• Avoid and correct hypotension
TARGETED TEMPERATURE
MANAGEMENT

• Targeted Temperature
Management (TTM)
between 32°C and 36°C
• Continue TTM beyond 24
hours by actively preventing
fever if patient still
comatose.
• Routine prehospital cooling
of patients with rapid
infusion of cold IV fluids is
not recommended (no
benefit, possible
complications)
PROGNOSTICATION FOR POOR
OUTCOME USING CLINICAL EXAM
• Patients not treated with TTM
–72 hours or later after cardiac arrest
–Longer interval after cardiac arrest (ie, beyond 72 hours)
needed if residual effect of sedation or paralysis is
suspected to confound clinical exam.
• Patients treated with TTM
–Reasonable to wait 72 hours after return to normothermia
if sedation or paralysis could confound clinical
examination
POTENTIAL ORGAN DONORS POST-
CARDIAC ARREST
• All patients resuscitated from cardiac arrest
who progress to death or brain death
should be evaluated as potential organ
donors.
• Patients who do not achieve ROSC and
would otherwise have resuscitation
terminated may be considered as potential
kidney or liver donors in settings where
rapid organ recovery programs exist.
QUESTIONS?