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Todd M.

Larabee, MD Department of Emergency Medicine University of Colorado Denver SOM

Issues after 2005 Guideline changes ILCOR Process Highlights of the 2010 Guidelines BLS ACLS PALS Summary

Biggest changes in 2005 were 30:2 compression ration and the change in defibrillation sequence Growing emphasis on high-quality CPR Implementation of the 2005 guidelines did improve outcomes Implementing new guidelines can take 18 months-4 years

Since 2005, theres been an emphasis to simplify CPR recommendations Stress high-quality CPR Stress utility/importance of bystander CPR Need to remove barriers to performance of bystander CPR De-emphasis on devices and drugs Importance of post-cardiac arrest care Importance of continuing education and training

Objectives:
Provide a forum for discussion and coordination of all aspects of cardiopulmonary and cerebral resuscitation worldwide. Foster scientific research in areas of resuscitation where there is a lack of data or controversy exists. Disseminate information on training and education in resuscitation. Provide a mechanism for collecting, reviewing and sharing international resuscitation data. Produce statements on specific issues related to resuscitation that reflect international consensus.

Resuscitation Council of Asia (current members Japan, Korea, Singapore, Taiwan)

Task Forces generate worksheets/PICO questions 411 scientific evidence reviews on 277 topics related to resuscitation and ECC 356 experts from 29 countries Debates/discussions via telephone/inperson/webinars Creates the most current and comprehensive review of resuscitation literature ever published

In adult patients in cardiac arrest (asystole, pulseless electrical activity, pulseless VT and VF) (prehospital [OHCA], in-hospital [IHCA]) (P), does the use of vasopressors (epinephrine, norepinephrine, others) or combination of vasopressors (I) compared with not using drugs (or a standard drug regimen) (C), improve outcomes (eg. ROSC, survival) (O).

Levels of Evidence for Therapeutic Interventions LOE 1: Randomised Controlled Trials (or meta-analyses of RCTs) LOE 2: Studies using concurrent controls without true randomisation (eg. pseudo-randomised) (or meta-analyses of such studies) LOE 3: Studies using retrospective controls LOE 4: Studies without a control group (eg. case series)

LOE 5: Studies not directly related to the specific patient/population (eg. different patient/population, animal models, mechanical models etc.)

Evidence Supporting Clinical Question


Good (Goetting and Paradis 1991)A-D (Grmec and Mally 2006)A-C (Gonzalez, Ornato et al. 1989)E (Lindner, Prengel et al. 1996)A-D

Fair

(Paradis, Martin et al. 1991)E

(Barton and Callaham 1991)A (Matok, Vardi et al. 2007)A-C

Poor

(Guyette, Guimond et al. 2004)A, E 1 2 3 Level of evidence

(Goetting and Paradis 1989)A 4 5

A = Return of spontaneous circulation C = Survival to hospital discharge B = Survival of event D = Intact neurological survival

E = Other endpoint Italics = Animal studies

Neutral evidence table


Good (Aung and Htay 2005)A-D (Brown, Martin et al. 1992)A-D (Callaway, Hostler et al. 2006)A-D (Choux, Gueugniaud et al. 1995)A-D (Gueugniaud, David et al. 2008)A-D (Gueugniaud, Mols et al. 1998)A-D (Lindner, Dirks et al. 1997)A-D (Lindner, Ahnefeld et al. 1991)A-C (Lipman, Wilson et al. 1993) A,B,E (Olson, Thakur et al. 1989)A-C (Olasveengen, Sunde et al. 2009)A-D (Callaham, Madsen et al. 1992)A-D (Lindner, Ahnefeld et al. 1991) A-C (Patrick, Freedman et al. 1995)A-D (Perondi, Reis et al. 2004)A-C (Sherman, Munger et al. 1997)A-C (Stiell, Hebert et al. 1992)A-D (Stiell, Hebert et al. 2001)A-E (Turner, Parsons et al. 1988)A-D (Wenzel, Krismer et al. 2004)A-D (Patterson, Boenning et al. 2005)A-D (Silfvast, Saarnivaara et al. 1985)A (Vandycke and Martens 2000)A-D (Takeo, Kosaku et al. 2009)A-D

(Carvolth and Hamilton 1996)A-C

Fair

(Herlitz, Ekstrom et al. 1995)A-C

(Carpenter and Stenmark 1997)A-D (Dieckmann and Vardis 1995)A-D (Mally, Jelatancev et al. 2007)A-C, E (Callaham, Barton et al. 1991)B-E (Ong, Tan et al. 2007)A-D 3

Poor

(Woodhouse, Cox et al. 1995)A-C

(Morris, Dereczyk et al. 1997) E (Gonzalez, Ornato et al. 1988)E 2 Level of evidence

A = ROSC C = Survival to hospital discharge B = Survival of event D = Intact neurological survival

E = Other endpoint

Opposing evidence table


Good (Behringer, Kittler et al. 1998)A,D

Fair

Poor (Rivers, Wortsman et al. 1994)A, B, E

(Chang, Ma et al. 2007)E (Duncan, Meaney et al. 2009)A-E 3 4 5

2 Level of evidence

A = Return of spontaneous circulation C = Survival to hospital discharge B = Survival of event D = Intact neurological survival

E = Other endpoint Italics = Animal studies

Look, listen, feel removed from algorithm


delays

Early activation of EMS Compression-only CPR for the untrained layrescuer High-quality CPR Minimize interruptions Deemphasis on pulse checks during CPR

C-A-B not A-B-C Most arrest are adult; most survivors are VF/VT Emphasis on performing high-quality CPR and early defibrillation Delay in C when attempting A May remove barriers to bystander CPR

Untrained lay-person Trained lay-person

Hands-only CPR Continue until AED/trained personnel available


Hands-only CPR If willing to perform ventilations with 30:2 ratio Continue until AED/trained personnel available CPR including ventilations with 30:2 ratio Can tailor sequence of interventions based on cause of arrest

Healthcare Provider

CPR Techniques and Devices

No adjunct has been shown to be superior to manual CPR ITD (ResQPOD) improved ROSC and short-term survival Load-band CPR (Autopulse) with no change in 4hr survival and worsened neurologic outcomes Mechanical piston devices with varying degrees of success All require additional equipment and training; training needs to be ongoing More research needed

Electrical Therapy
Emphasis on AEDs and addition of AEDs to enhance the chain of survival CPR before defibrillation remains unclear Continuing with 1-shock protocol with minimizing CPR interruptions

Successful ACLS is predicated on good BLS


High-quality CPR with minimal interruptions Early defibrillation

Fifth link in Chain of Survival: PostCardiac Arrest Care


Multidisciplinary care from BLS to discharge for good neurologic outcome

Qualitative waveform capnography

Airway Management:
Qualitative waveform capnography recommended Suppraglottic airway devices are supported as airway alternative Cricoid pressure is no longer recommended

Symptomatic Dysrrhythmias
Adenosine is safe for diagnostics in stable, undifferentiated wide-complex monomorphic tachycardia For stable or unstable bradycardia, IV chronotropic agents recommended as equally effective as external pacing

ACLS Cardiac Arrest Circular Algorithm

Neumar, R. W. et al. Circulation 2010;122:S729-S767

Copyright 2010 American Heart Association

ACLS Cardiac Arrest Algorithm

Neumar, R. W. et al. Circulation 2010;122:S729-S767

Copyright 2010 American Heart Association

Notice on the charts:


Vascular access, drug delivery, advanced airway placement are recommended but should not interrupt CPR Atropine no longer recommended for PEA/asystole Real-time monitoring of CPR quality
Mechanical parameters Physiologic parameters

Post-arrest care now a component of the algorithm

Post Cardiac-Arrest Care Key Objectives

Multidisciplinary team Structured, integrated, bundled system of care Optimize cardiopulmonary function and vital organ perfusion after ROSC Transport to an appropriate critical care unit with comprehensive post-cardiac arrest care system Identify/intervention for ACS Temperature control for improving neurologic outcomes Prevention and treatment of multi-organ dysfunction

Emphasis on asphyxial arrest combined with chest compressions Compression-only CPR for bystanders unwilling or unable to perform ventilations C-A-B for ease of teaching (A-B-C continues in Neonatal Resuscitation) High-quality CPR

Deemphasis on pulse checks Updated formula for cuffed tubes in infants and young children
Uncuffed: Cuffed: 4 + (age/4) if > 2yr 3.5 up to 1 yr, 4.0 if >1yr 3.5 + (age/4) if >2yr 3.0 up to 1yr, 3.5 if >1yr

Safety and value of cricoid pressure questioned; can discontinue if impedes airway

Capnography recommended Optimal defibrillation energy dose uncertainrecommending 2-4J/kg (either waveform) Concerns of hyperoxemia after ROSC

Fewer, less dramatic changes than in 2005 Circulation more important than ventilation in most instances C-A-B Goodbye Atropine Post resuscitation care and neurologic outcomes focus

Thanks for listening.