New Changes to Old Friends

An overview of the 2010 ECC recommendations for ADULT CPR and Emergency Cardiovascular Care (ECC)

Objectives

Discuss the 2010 changes to ECC and CPR

Discuss and review the importance of CPR and the clinical methods to maximize its effectiveness

Credit where Credit is Due

Adapted from presentation by Ahamed Idris MD Professor of Emergency Medicine

University of Texas Southwestern Medical Center at Dallas

American Heart Association Circulation documents

Special Thanks

bull Dr Peter Safarbull Father of Resuscitation

medicinebull Helped develop CPRbull Directly responsible for

the research used today in therapeutic hypothermia

EVIDENCE BASED MEDICINE

Using material from Sayre MR OrsquoConnor RE Atkins DL Billi JE Callaway CW Shuster M Eigel B Montgomery WH Hickey RW Jacobs I Nadkarni VM Morley PT Semenko TI

Hazinski MF Part 2 evidence evaluation and management of potential or perceived conflicts of interest 2010 American Heart Association Guidelines for

Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010122(suppl 3)S657ndashS664

Levels of Evidence Used to be 7 (or 8 ) different

ILCOR levels of Evidence (LOE) In 2010 ILCOR reduced these to

5 The AHA has broken these into

three broad categories

Level A ndash Highest standard of evidence

Level B ndash Most common Level C ndash Anecdotal case reports

consensus opinions retrospective studies small studies previous standard of care without evidence to contrary

Levels of Evidence

KEY POINT

ldquo A recommendation with Level of Evidence B or C does not imply that the recommendation is weak Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials Even though randomized trials are not available there may be a very clear clinical consensus that a particular test or therapy is useful or effectiverdquo

- 2010 AHA ECC GuidelinesCirculation 2010122S657-S664

Classes of Recommendations

bull Most previous classes retained with better clarifications and descriptions

bullldquoClass Indeterminaterdquo recommendations which were used in 2005 are not included in the 2010 AHA Guidelines for CPR and ECC The elimination of the term ldquoClass Indeterminaterdquo is consistent with the ACCFndashAHA Classes of Recommendation

bullWhen the AHA writing groups felt that the evidence was insufficient to offer a recommendation either for or against the use of a drug or intervention no recommendation was given

ETHICAL CONSIDERATIONS IN ECC

Using material from

Morrison LJ Kierzek G Diekema DS Sayre MR Silvers SM Idris AH Mancini ME Part 3 ethics 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010122(suppl 3)S665ndashS675

ECC and DEATH

New TERMS DNR

DNAR Do not attempt Resuscitation AND Allow Natural Death

Principle of Futility Defined as lt1 chance of success or

positive outcome

Withholding Resuscitation

Mild changes in verbage Situations where attempts to perform CPR

would place the rescuer at risk of serious injury or mortal peril

Obvious clinical signs of irreversible death (eg rigor-mortis dependent lividity decapitation transection or decomposition)

A valid signed and dated advance directive indicating that resuscitation is not desired or a valid signed and dated DNAR order

Termination of Resuscitation- BLS when ALS is not available or delayed

All 3 of the following criteria must be present before moving to the ambulance for transport to consider terminating BLS resuscitative attempts for adult victims of out-of-hospital cardiac arrest (1)Arrest was not witnessed by EMS provider or first responder (2) No return of spontaneous circulation (ROSC) after 3 full rounds of CPR and automated external defibrillator (AED) analysis (3) and no AED shocks were deliveredThis is to be used in conjunction with consultation with real time on line medical control

(Class IIb LOE A)

Termination of Resuscitation- ALS

All 3 of the following criteria must be present before moving to the ambulance for transport to consider terminating BLS and ALS resuscitative attempts for adult victims of out-of-hospital cardiac arrest (1)Arrest was not witnessed by EMS provider or first responder (2) No return of spontaneous circulation (ROSC) after ldquofull ALS carerdquo (defined as 20 minutes of ALS and an advanced airway (3) and no AED shocks were delivered prior to ALS arrival

(Class IIa LOE B)

Why Terminate

Termination of Resuscitative Efforts and Transport Implications

Field termination reduces unnecessary transport to the hospital by 60 with the BLS rule and 40 with the ALS rule reducing associated road hazards that put the provider patient and public at risk

In addition field termination reduces inadvertent paramedic exposure to potential biohazards and the higher cost of ED pronouncement

More importantly the quality of CPR is compromised during transport and survival is linked to optimizing scene care rather than rushing to hospital

Termination of Resuscitation in Pediatrics

No predictors of neonatal or pediatric (infant or child) out-of hospital resuscitation success or failure have been established

No validated clinical decision rules have been derived and evaluated Further research in this area is needed

In the absence of clinical decision rules for the neonatal or pediatric OHCA victim the responsible prehospital provider should follow BLS pediatric and advanced cardiovascular life support protocols and consult with real-time medical direction or transport the victim to the most appropriate facility per local directives

Other Ethical Questions we did not discuss that are in the AHA documents

In hospital cardiac arrest ethical decisions

Withholding and withdrawing care in the newborn and neonate especially pre-term and low birthweight

Organ and Tissue Donation after resuscitation

Ethics of resuscitation research Ethics of training on the newly dead

CPR WIN (Whats Important Now)

90 of all changes to 2010 ECC are right in the BLS segment

Builds on and further enhances the changes and research discussed in the 2005 guidelines

COMPRESSIONS are the single most emphasized segment of resuscitation

GOOD and SUSTAINED Coronary Perfusion Pressure is the GOAL

Understanding CPP

Coronary Perfusion Pressure (CPP) is essential to ROSC

When arrest is present for more than a few minutes the myocardium is depleted of oxygen and metabolic substrates

A brief period of (good and sustained) chest compressions can deliver oxygen and energy substrates (ie ATP) increasing the likelihood that a shock may terminate VF (defibrillation) and a perfusing rhythm will return (ie ROSC)

Without this a shock may result in ldquoSECONDARY ASYSTOLErdquo

GOOD and SUSTAINED CPP results in higher levels of myocardial ATP and survival

3 Phase Model

Understanding Coronary Perfusion Pressure

Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure

ROSC Associated with CPP

Overview of ECC 2010 Changes

Hands Only CPR

Single biggest change ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons

Hands Only CPR

Of note some healthcare providers and laypersons indicate that reluctance to perform mouth-to-mouth ventilation for victims of cardiac arrest is a theoretical and potential barrier to performing bystander CPR

When actual bystanders were interviewed however such reluctance was not expressed panic was cited as the major obstacle to laypersons performance of bystander CPR

The simpler Hands-Only technique may help overcome panic and hesitation to act in both regards

KEY POINT

HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR in LAY RESCUERS

This presumes that traditional CPR with ventilation will eventually be performed

The exact interval in which hands only CPR is more beneficial over traditional CPR is not known

CAB

Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

Confusion in Agonal Respirations vs Good Respirations

The rescuer should treat the victim who has occasional gasps as if he or she is not breathing (Class ILOE C)

The HCP will combine their assessment for respirations with assessment for responsiveness

The Layperson will assume that if the patient is completely unresponsive they have ineffective respirations

A simultaneous choreographed approach Much more emphasis on the team approach and a realistic

recognition of what and how PARAMEDICS do their job

Recognition that resuscitation is not a ldquolinierrdquo process (Step A THEN Step B etc) but a simultaneous series of actions

ldquohellipin a highly specialized environment such as a critical care unit of a hospital many of the individual components of CPR (compression-ventilation-defibrillation) may be managed simultaneously This approach requires choreography among many highly-trained rescuers who work as an integrated team

In the pre-hospital setting the order of the CPR components performed by the healthcare provider may switch between a sequenced and choreographed model depending on the proficiency of the provider and the availability of resourcesrdquo

- Circulation 2010122[suppl 3]S676 ndashS684

ldquo It is reasonable for healthcare providers to tailor the sequence of rescue actions to the most likely cause of arrestrdquo

THIS MEANS NO MORE COOK-BOOK MEDICINE

New CPR Guidelines

Traditional Healthcare Version

2005 to 2010 changes

Component of CPR

2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

PULSE CHECK HCP Only HCP only Checking for ldquoDEFNITE pulserdquo

SOME THINGS REMAIN IMPORTANTSOME THINGS REMAIN IMPORTANT

RATERATE

DEPTHDEPTH

RELEASERELEASE

UNINTERRUPTEDUNINTERRUPTED

DECREASED DECREASED VENTILATIONVENTILATION

5 KEY5 KEY ASPECTSASPECTS

OFOF GOODGOOD CPRCPR

Compression Rate (at least 100 Minute)

Rate per minute is NOT a function of ldquospeedrdquo of compressions only but a function of both speed ands minimizing no-flow periods (discussed later) for a total compressionsminute

Compressions rates as high as 130 resulted in favorable outcomes

Compression rates lt87minute saw rapid drop off in ROSC

NEW RECOMMENDATION At LEAST 100minute

Better too fast than too slow

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

76

75

58

42

Compression Rate

Target = ~100min with complete release Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH (At least 2 inches)

Previous studies show that only about 27 of compressions were deep enough (Wik 2005)

0 (none) were too deep NEW GIUDELINES The adult sternum

should be depressed at least 2 inches (5 cm) (Class IIa LOE B) with chest compression and chest recoilrelaxation times approximately equal (Class IIb LOE C)

Compression DEPTH

Target = 38-51 mm with complete release Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Complete RELEASERECOIL (Full)

Complete Recoil essential to reduce intrathoracic pressure between compressions

Reducing recoil improves hemodynamics in arrest and improves Coronary Perfusion Pressure (CPP)

Incomplete chest wall recoil can be reduced during CPR by using electronic recording devices that provide real-time feedback

Niles D Nysaether J Sutton R Nishisaki A Abella BS Arbogast K Maltese MR Berg RA Helfaer M Nadkarni V Leaning is common during in-hospital

pediatric CPR and decreased with automated corrective feedback Resuscitation 200980553ndash557

Intra-thoracic Pressure and CPR

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and Recoil

Abella et al 2005 Circulation

INTURRUPTIONS

Pausing for procedures intubation IV pulse check etc)

Pausing for rhythm analysis Pausing after shock to await post-

shock rhythm Pausing to charge clear and shock Unaware of importance of CPR in

ldquobig picturerdquo

No-Flow Ratio (Interruption of CPR)

Target = less than 20 Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

KEY POINT

ldquohellipHigh-quality CPR is important not only at the onset but throughout the course of resuscitation Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPRrdquo

AHA 2010 Guidelines

DECREASING VENTILATION

CPR with Advanced Airway 8 ndash 10 breathsminute

Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Objectives

Discuss the 2010 changes to ECC and CPR

Discuss and review the importance of CPR and the clinical methods to maximize its effectiveness

Credit where Credit is Due

Adapted from presentation by Ahamed Idris MD Professor of Emergency Medicine

University of Texas Southwestern Medical Center at Dallas

American Heart Association Circulation documents

Special Thanks

bull Dr Peter Safarbull Father of Resuscitation

medicinebull Helped develop CPRbull Directly responsible for

the research used today in therapeutic hypothermia

EVIDENCE BASED MEDICINE

Using material from Sayre MR OrsquoConnor RE Atkins DL Billi JE Callaway CW Shuster M Eigel B Montgomery WH Hickey RW Jacobs I Nadkarni VM Morley PT Semenko TI

Hazinski MF Part 2 evidence evaluation and management of potential or perceived conflicts of interest 2010 American Heart Association Guidelines for

Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010122(suppl 3)S657ndashS664

Levels of Evidence Used to be 7 (or 8 ) different

ILCOR levels of Evidence (LOE) In 2010 ILCOR reduced these to

5 The AHA has broken these into

three broad categories

Level A ndash Highest standard of evidence

Level B ndash Most common Level C ndash Anecdotal case reports

consensus opinions retrospective studies small studies previous standard of care without evidence to contrary

Levels of Evidence

KEY POINT

ldquo A recommendation with Level of Evidence B or C does not imply that the recommendation is weak Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials Even though randomized trials are not available there may be a very clear clinical consensus that a particular test or therapy is useful or effectiverdquo

- 2010 AHA ECC GuidelinesCirculation 2010122S657-S664

Classes of Recommendations

bull Most previous classes retained with better clarifications and descriptions

bullldquoClass Indeterminaterdquo recommendations which were used in 2005 are not included in the 2010 AHA Guidelines for CPR and ECC The elimination of the term ldquoClass Indeterminaterdquo is consistent with the ACCFndashAHA Classes of Recommendation

bullWhen the AHA writing groups felt that the evidence was insufficient to offer a recommendation either for or against the use of a drug or intervention no recommendation was given

ETHICAL CONSIDERATIONS IN ECC

Using material from

Morrison LJ Kierzek G Diekema DS Sayre MR Silvers SM Idris AH Mancini ME Part 3 ethics 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010122(suppl 3)S665ndashS675

ECC and DEATH

New TERMS DNR

DNAR Do not attempt Resuscitation AND Allow Natural Death

Principle of Futility Defined as lt1 chance of success or

positive outcome

Withholding Resuscitation

Mild changes in verbage Situations where attempts to perform CPR

would place the rescuer at risk of serious injury or mortal peril

Obvious clinical signs of irreversible death (eg rigor-mortis dependent lividity decapitation transection or decomposition)

A valid signed and dated advance directive indicating that resuscitation is not desired or a valid signed and dated DNAR order

Termination of Resuscitation- BLS when ALS is not available or delayed

All 3 of the following criteria must be present before moving to the ambulance for transport to consider terminating BLS resuscitative attempts for adult victims of out-of-hospital cardiac arrest (1)Arrest was not witnessed by EMS provider or first responder (2) No return of spontaneous circulation (ROSC) after 3 full rounds of CPR and automated external defibrillator (AED) analysis (3) and no AED shocks were deliveredThis is to be used in conjunction with consultation with real time on line medical control

(Class IIb LOE A)

Termination of Resuscitation- ALS

All 3 of the following criteria must be present before moving to the ambulance for transport to consider terminating BLS and ALS resuscitative attempts for adult victims of out-of-hospital cardiac arrest (1)Arrest was not witnessed by EMS provider or first responder (2) No return of spontaneous circulation (ROSC) after ldquofull ALS carerdquo (defined as 20 minutes of ALS and an advanced airway (3) and no AED shocks were delivered prior to ALS arrival

(Class IIa LOE B)

Why Terminate

Termination of Resuscitative Efforts and Transport Implications

Field termination reduces unnecessary transport to the hospital by 60 with the BLS rule and 40 with the ALS rule reducing associated road hazards that put the provider patient and public at risk

In addition field termination reduces inadvertent paramedic exposure to potential biohazards and the higher cost of ED pronouncement

More importantly the quality of CPR is compromised during transport and survival is linked to optimizing scene care rather than rushing to hospital

Termination of Resuscitation in Pediatrics

No predictors of neonatal or pediatric (infant or child) out-of hospital resuscitation success or failure have been established

No validated clinical decision rules have been derived and evaluated Further research in this area is needed

In the absence of clinical decision rules for the neonatal or pediatric OHCA victim the responsible prehospital provider should follow BLS pediatric and advanced cardiovascular life support protocols and consult with real-time medical direction or transport the victim to the most appropriate facility per local directives

Other Ethical Questions we did not discuss that are in the AHA documents

In hospital cardiac arrest ethical decisions

Withholding and withdrawing care in the newborn and neonate especially pre-term and low birthweight

Organ and Tissue Donation after resuscitation

Ethics of resuscitation research Ethics of training on the newly dead

CPR WIN (Whats Important Now)

90 of all changes to 2010 ECC are right in the BLS segment

Builds on and further enhances the changes and research discussed in the 2005 guidelines

COMPRESSIONS are the single most emphasized segment of resuscitation

GOOD and SUSTAINED Coronary Perfusion Pressure is the GOAL

Understanding CPP

Coronary Perfusion Pressure (CPP) is essential to ROSC

When arrest is present for more than a few minutes the myocardium is depleted of oxygen and metabolic substrates

A brief period of (good and sustained) chest compressions can deliver oxygen and energy substrates (ie ATP) increasing the likelihood that a shock may terminate VF (defibrillation) and a perfusing rhythm will return (ie ROSC)

Without this a shock may result in ldquoSECONDARY ASYSTOLErdquo

GOOD and SUSTAINED CPP results in higher levels of myocardial ATP and survival

3 Phase Model

Understanding Coronary Perfusion Pressure

Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure

ROSC Associated with CPP

Overview of ECC 2010 Changes

Hands Only CPR

Single biggest change ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons

Hands Only CPR

Of note some healthcare providers and laypersons indicate that reluctance to perform mouth-to-mouth ventilation for victims of cardiac arrest is a theoretical and potential barrier to performing bystander CPR

When actual bystanders were interviewed however such reluctance was not expressed panic was cited as the major obstacle to laypersons performance of bystander CPR

The simpler Hands-Only technique may help overcome panic and hesitation to act in both regards

KEY POINT

HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR in LAY RESCUERS

This presumes that traditional CPR with ventilation will eventually be performed

The exact interval in which hands only CPR is more beneficial over traditional CPR is not known

CAB

Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

Confusion in Agonal Respirations vs Good Respirations

The rescuer should treat the victim who has occasional gasps as if he or she is not breathing (Class ILOE C)

The HCP will combine their assessment for respirations with assessment for responsiveness

The Layperson will assume that if the patient is completely unresponsive they have ineffective respirations

A simultaneous choreographed approach Much more emphasis on the team approach and a realistic

recognition of what and how PARAMEDICS do their job

Recognition that resuscitation is not a ldquolinierrdquo process (Step A THEN Step B etc) but a simultaneous series of actions

ldquohellipin a highly specialized environment such as a critical care unit of a hospital many of the individual components of CPR (compression-ventilation-defibrillation) may be managed simultaneously This approach requires choreography among many highly-trained rescuers who work as an integrated team

In the pre-hospital setting the order of the CPR components performed by the healthcare provider may switch between a sequenced and choreographed model depending on the proficiency of the provider and the availability of resourcesrdquo

- Circulation 2010122[suppl 3]S676 ndashS684

ldquo It is reasonable for healthcare providers to tailor the sequence of rescue actions to the most likely cause of arrestrdquo

THIS MEANS NO MORE COOK-BOOK MEDICINE

New CPR Guidelines

Traditional Healthcare Version

2005 to 2010 changes

Component of CPR

2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

PULSE CHECK HCP Only HCP only Checking for ldquoDEFNITE pulserdquo

SOME THINGS REMAIN IMPORTANTSOME THINGS REMAIN IMPORTANT

RATERATE

DEPTHDEPTH

RELEASERELEASE

UNINTERRUPTEDUNINTERRUPTED

DECREASED DECREASED VENTILATIONVENTILATION

5 KEY5 KEY ASPECTSASPECTS

OFOF GOODGOOD CPRCPR

Compression Rate (at least 100 Minute)

Rate per minute is NOT a function of ldquospeedrdquo of compressions only but a function of both speed ands minimizing no-flow periods (discussed later) for a total compressionsminute

Compressions rates as high as 130 resulted in favorable outcomes

Compression rates lt87minute saw rapid drop off in ROSC

NEW RECOMMENDATION At LEAST 100minute

Better too fast than too slow

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

76

75

58

42

Compression Rate

Target = ~100min with complete release Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH (At least 2 inches)

Previous studies show that only about 27 of compressions were deep enough (Wik 2005)

0 (none) were too deep NEW GIUDELINES The adult sternum

should be depressed at least 2 inches (5 cm) (Class IIa LOE B) with chest compression and chest recoilrelaxation times approximately equal (Class IIb LOE C)

Compression DEPTH

Target = 38-51 mm with complete release Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Complete RELEASERECOIL (Full)

Complete Recoil essential to reduce intrathoracic pressure between compressions

Reducing recoil improves hemodynamics in arrest and improves Coronary Perfusion Pressure (CPP)

Incomplete chest wall recoil can be reduced during CPR by using electronic recording devices that provide real-time feedback

Niles D Nysaether J Sutton R Nishisaki A Abella BS Arbogast K Maltese MR Berg RA Helfaer M Nadkarni V Leaning is common during in-hospital

pediatric CPR and decreased with automated corrective feedback Resuscitation 200980553ndash557

Intra-thoracic Pressure and CPR

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and Recoil

Abella et al 2005 Circulation

INTURRUPTIONS

Pausing for procedures intubation IV pulse check etc)

Pausing for rhythm analysis Pausing after shock to await post-

shock rhythm Pausing to charge clear and shock Unaware of importance of CPR in

ldquobig picturerdquo

No-Flow Ratio (Interruption of CPR)

Target = less than 20 Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

KEY POINT

ldquohellipHigh-quality CPR is important not only at the onset but throughout the course of resuscitation Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPRrdquo

AHA 2010 Guidelines

DECREASING VENTILATION

CPR with Advanced Airway 8 ndash 10 breathsminute

Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Credit where Credit is Due

Adapted from presentation by Ahamed Idris MD Professor of Emergency Medicine

University of Texas Southwestern Medical Center at Dallas

American Heart Association Circulation documents

Special Thanks

bull Dr Peter Safarbull Father of Resuscitation

medicinebull Helped develop CPRbull Directly responsible for

the research used today in therapeutic hypothermia

EVIDENCE BASED MEDICINE

Using material from Sayre MR OrsquoConnor RE Atkins DL Billi JE Callaway CW Shuster M Eigel B Montgomery WH Hickey RW Jacobs I Nadkarni VM Morley PT Semenko TI

Hazinski MF Part 2 evidence evaluation and management of potential or perceived conflicts of interest 2010 American Heart Association Guidelines for

Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010122(suppl 3)S657ndashS664

Levels of Evidence Used to be 7 (or 8 ) different

ILCOR levels of Evidence (LOE) In 2010 ILCOR reduced these to

5 The AHA has broken these into

three broad categories

Level A ndash Highest standard of evidence

Level B ndash Most common Level C ndash Anecdotal case reports

consensus opinions retrospective studies small studies previous standard of care without evidence to contrary

Levels of Evidence

KEY POINT

ldquo A recommendation with Level of Evidence B or C does not imply that the recommendation is weak Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials Even though randomized trials are not available there may be a very clear clinical consensus that a particular test or therapy is useful or effectiverdquo

- 2010 AHA ECC GuidelinesCirculation 2010122S657-S664

Classes of Recommendations

bull Most previous classes retained with better clarifications and descriptions

bullldquoClass Indeterminaterdquo recommendations which were used in 2005 are not included in the 2010 AHA Guidelines for CPR and ECC The elimination of the term ldquoClass Indeterminaterdquo is consistent with the ACCFndashAHA Classes of Recommendation

bullWhen the AHA writing groups felt that the evidence was insufficient to offer a recommendation either for or against the use of a drug or intervention no recommendation was given

ETHICAL CONSIDERATIONS IN ECC

Using material from

Morrison LJ Kierzek G Diekema DS Sayre MR Silvers SM Idris AH Mancini ME Part 3 ethics 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010122(suppl 3)S665ndashS675

ECC and DEATH

New TERMS DNR

DNAR Do not attempt Resuscitation AND Allow Natural Death

Principle of Futility Defined as lt1 chance of success or

positive outcome

Withholding Resuscitation

Mild changes in verbage Situations where attempts to perform CPR

would place the rescuer at risk of serious injury or mortal peril

Obvious clinical signs of irreversible death (eg rigor-mortis dependent lividity decapitation transection or decomposition)

A valid signed and dated advance directive indicating that resuscitation is not desired or a valid signed and dated DNAR order

Termination of Resuscitation- BLS when ALS is not available or delayed

All 3 of the following criteria must be present before moving to the ambulance for transport to consider terminating BLS resuscitative attempts for adult victims of out-of-hospital cardiac arrest (1)Arrest was not witnessed by EMS provider or first responder (2) No return of spontaneous circulation (ROSC) after 3 full rounds of CPR and automated external defibrillator (AED) analysis (3) and no AED shocks were deliveredThis is to be used in conjunction with consultation with real time on line medical control

(Class IIb LOE A)

Termination of Resuscitation- ALS

All 3 of the following criteria must be present before moving to the ambulance for transport to consider terminating BLS and ALS resuscitative attempts for adult victims of out-of-hospital cardiac arrest (1)Arrest was not witnessed by EMS provider or first responder (2) No return of spontaneous circulation (ROSC) after ldquofull ALS carerdquo (defined as 20 minutes of ALS and an advanced airway (3) and no AED shocks were delivered prior to ALS arrival

(Class IIa LOE B)

Why Terminate

Termination of Resuscitative Efforts and Transport Implications

Field termination reduces unnecessary transport to the hospital by 60 with the BLS rule and 40 with the ALS rule reducing associated road hazards that put the provider patient and public at risk

In addition field termination reduces inadvertent paramedic exposure to potential biohazards and the higher cost of ED pronouncement

More importantly the quality of CPR is compromised during transport and survival is linked to optimizing scene care rather than rushing to hospital

Termination of Resuscitation in Pediatrics

No predictors of neonatal or pediatric (infant or child) out-of hospital resuscitation success or failure have been established

No validated clinical decision rules have been derived and evaluated Further research in this area is needed

In the absence of clinical decision rules for the neonatal or pediatric OHCA victim the responsible prehospital provider should follow BLS pediatric and advanced cardiovascular life support protocols and consult with real-time medical direction or transport the victim to the most appropriate facility per local directives

Other Ethical Questions we did not discuss that are in the AHA documents

In hospital cardiac arrest ethical decisions

Withholding and withdrawing care in the newborn and neonate especially pre-term and low birthweight

Organ and Tissue Donation after resuscitation

Ethics of resuscitation research Ethics of training on the newly dead

CPR WIN (Whats Important Now)

90 of all changes to 2010 ECC are right in the BLS segment

Builds on and further enhances the changes and research discussed in the 2005 guidelines

COMPRESSIONS are the single most emphasized segment of resuscitation

GOOD and SUSTAINED Coronary Perfusion Pressure is the GOAL

Understanding CPP

Coronary Perfusion Pressure (CPP) is essential to ROSC

When arrest is present for more than a few minutes the myocardium is depleted of oxygen and metabolic substrates

A brief period of (good and sustained) chest compressions can deliver oxygen and energy substrates (ie ATP) increasing the likelihood that a shock may terminate VF (defibrillation) and a perfusing rhythm will return (ie ROSC)

Without this a shock may result in ldquoSECONDARY ASYSTOLErdquo

GOOD and SUSTAINED CPP results in higher levels of myocardial ATP and survival

3 Phase Model

Understanding Coronary Perfusion Pressure

Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure

ROSC Associated with CPP

Overview of ECC 2010 Changes

Hands Only CPR

Single biggest change ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons

Hands Only CPR

Of note some healthcare providers and laypersons indicate that reluctance to perform mouth-to-mouth ventilation for victims of cardiac arrest is a theoretical and potential barrier to performing bystander CPR

When actual bystanders were interviewed however such reluctance was not expressed panic was cited as the major obstacle to laypersons performance of bystander CPR

The simpler Hands-Only technique may help overcome panic and hesitation to act in both regards

KEY POINT

HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR in LAY RESCUERS

This presumes that traditional CPR with ventilation will eventually be performed

The exact interval in which hands only CPR is more beneficial over traditional CPR is not known

CAB

Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

Confusion in Agonal Respirations vs Good Respirations

The rescuer should treat the victim who has occasional gasps as if he or she is not breathing (Class ILOE C)

The HCP will combine their assessment for respirations with assessment for responsiveness

The Layperson will assume that if the patient is completely unresponsive they have ineffective respirations

A simultaneous choreographed approach Much more emphasis on the team approach and a realistic

recognition of what and how PARAMEDICS do their job

Recognition that resuscitation is not a ldquolinierrdquo process (Step A THEN Step B etc) but a simultaneous series of actions

ldquohellipin a highly specialized environment such as a critical care unit of a hospital many of the individual components of CPR (compression-ventilation-defibrillation) may be managed simultaneously This approach requires choreography among many highly-trained rescuers who work as an integrated team

In the pre-hospital setting the order of the CPR components performed by the healthcare provider may switch between a sequenced and choreographed model depending on the proficiency of the provider and the availability of resourcesrdquo

- Circulation 2010122[suppl 3]S676 ndashS684

ldquo It is reasonable for healthcare providers to tailor the sequence of rescue actions to the most likely cause of arrestrdquo

THIS MEANS NO MORE COOK-BOOK MEDICINE

New CPR Guidelines

Traditional Healthcare Version

2005 to 2010 changes

Component of CPR

2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

PULSE CHECK HCP Only HCP only Checking for ldquoDEFNITE pulserdquo

SOME THINGS REMAIN IMPORTANTSOME THINGS REMAIN IMPORTANT

RATERATE

DEPTHDEPTH

RELEASERELEASE

UNINTERRUPTEDUNINTERRUPTED

DECREASED DECREASED VENTILATIONVENTILATION

5 KEY5 KEY ASPECTSASPECTS

OFOF GOODGOOD CPRCPR

Compression Rate (at least 100 Minute)

Rate per minute is NOT a function of ldquospeedrdquo of compressions only but a function of both speed ands minimizing no-flow periods (discussed later) for a total compressionsminute

Compressions rates as high as 130 resulted in favorable outcomes

Compression rates lt87minute saw rapid drop off in ROSC

NEW RECOMMENDATION At LEAST 100minute

Better too fast than too slow

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

76

75

58

42

Compression Rate

Target = ~100min with complete release Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH (At least 2 inches)

Previous studies show that only about 27 of compressions were deep enough (Wik 2005)

0 (none) were too deep NEW GIUDELINES The adult sternum

should be depressed at least 2 inches (5 cm) (Class IIa LOE B) with chest compression and chest recoilrelaxation times approximately equal (Class IIb LOE C)

Compression DEPTH

Target = 38-51 mm with complete release Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Complete RELEASERECOIL (Full)

Complete Recoil essential to reduce intrathoracic pressure between compressions

Reducing recoil improves hemodynamics in arrest and improves Coronary Perfusion Pressure (CPP)

Incomplete chest wall recoil can be reduced during CPR by using electronic recording devices that provide real-time feedback

Niles D Nysaether J Sutton R Nishisaki A Abella BS Arbogast K Maltese MR Berg RA Helfaer M Nadkarni V Leaning is common during in-hospital

pediatric CPR and decreased with automated corrective feedback Resuscitation 200980553ndash557

Intra-thoracic Pressure and CPR

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and Recoil

Abella et al 2005 Circulation

INTURRUPTIONS

Pausing for procedures intubation IV pulse check etc)

Pausing for rhythm analysis Pausing after shock to await post-

shock rhythm Pausing to charge clear and shock Unaware of importance of CPR in

ldquobig picturerdquo

No-Flow Ratio (Interruption of CPR)

Target = less than 20 Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

KEY POINT

ldquohellipHigh-quality CPR is important not only at the onset but throughout the course of resuscitation Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPRrdquo

AHA 2010 Guidelines

DECREASING VENTILATION

CPR with Advanced Airway 8 ndash 10 breathsminute

Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Special Thanks

bull Dr Peter Safarbull Father of Resuscitation

medicinebull Helped develop CPRbull Directly responsible for

the research used today in therapeutic hypothermia

EVIDENCE BASED MEDICINE

Using material from Sayre MR OrsquoConnor RE Atkins DL Billi JE Callaway CW Shuster M Eigel B Montgomery WH Hickey RW Jacobs I Nadkarni VM Morley PT Semenko TI

Hazinski MF Part 2 evidence evaluation and management of potential or perceived conflicts of interest 2010 American Heart Association Guidelines for

Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010122(suppl 3)S657ndashS664

Levels of Evidence Used to be 7 (or 8 ) different

ILCOR levels of Evidence (LOE) In 2010 ILCOR reduced these to

5 The AHA has broken these into

three broad categories

Level A ndash Highest standard of evidence

Level B ndash Most common Level C ndash Anecdotal case reports

consensus opinions retrospective studies small studies previous standard of care without evidence to contrary

Levels of Evidence

KEY POINT

ldquo A recommendation with Level of Evidence B or C does not imply that the recommendation is weak Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials Even though randomized trials are not available there may be a very clear clinical consensus that a particular test or therapy is useful or effectiverdquo

- 2010 AHA ECC GuidelinesCirculation 2010122S657-S664

Classes of Recommendations

bull Most previous classes retained with better clarifications and descriptions

bullldquoClass Indeterminaterdquo recommendations which were used in 2005 are not included in the 2010 AHA Guidelines for CPR and ECC The elimination of the term ldquoClass Indeterminaterdquo is consistent with the ACCFndashAHA Classes of Recommendation

bullWhen the AHA writing groups felt that the evidence was insufficient to offer a recommendation either for or against the use of a drug or intervention no recommendation was given

ETHICAL CONSIDERATIONS IN ECC

Using material from

Morrison LJ Kierzek G Diekema DS Sayre MR Silvers SM Idris AH Mancini ME Part 3 ethics 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010122(suppl 3)S665ndashS675

ECC and DEATH

New TERMS DNR

DNAR Do not attempt Resuscitation AND Allow Natural Death

Principle of Futility Defined as lt1 chance of success or

positive outcome

Withholding Resuscitation

Mild changes in verbage Situations where attempts to perform CPR

would place the rescuer at risk of serious injury or mortal peril

Obvious clinical signs of irreversible death (eg rigor-mortis dependent lividity decapitation transection or decomposition)

A valid signed and dated advance directive indicating that resuscitation is not desired or a valid signed and dated DNAR order

Termination of Resuscitation- BLS when ALS is not available or delayed

All 3 of the following criteria must be present before moving to the ambulance for transport to consider terminating BLS resuscitative attempts for adult victims of out-of-hospital cardiac arrest (1)Arrest was not witnessed by EMS provider or first responder (2) No return of spontaneous circulation (ROSC) after 3 full rounds of CPR and automated external defibrillator (AED) analysis (3) and no AED shocks were deliveredThis is to be used in conjunction with consultation with real time on line medical control

(Class IIb LOE A)

Termination of Resuscitation- ALS

All 3 of the following criteria must be present before moving to the ambulance for transport to consider terminating BLS and ALS resuscitative attempts for adult victims of out-of-hospital cardiac arrest (1)Arrest was not witnessed by EMS provider or first responder (2) No return of spontaneous circulation (ROSC) after ldquofull ALS carerdquo (defined as 20 minutes of ALS and an advanced airway (3) and no AED shocks were delivered prior to ALS arrival

(Class IIa LOE B)

Why Terminate

Termination of Resuscitative Efforts and Transport Implications

Field termination reduces unnecessary transport to the hospital by 60 with the BLS rule and 40 with the ALS rule reducing associated road hazards that put the provider patient and public at risk

In addition field termination reduces inadvertent paramedic exposure to potential biohazards and the higher cost of ED pronouncement

More importantly the quality of CPR is compromised during transport and survival is linked to optimizing scene care rather than rushing to hospital

Termination of Resuscitation in Pediatrics

No predictors of neonatal or pediatric (infant or child) out-of hospital resuscitation success or failure have been established

No validated clinical decision rules have been derived and evaluated Further research in this area is needed

In the absence of clinical decision rules for the neonatal or pediatric OHCA victim the responsible prehospital provider should follow BLS pediatric and advanced cardiovascular life support protocols and consult with real-time medical direction or transport the victim to the most appropriate facility per local directives

Other Ethical Questions we did not discuss that are in the AHA documents

In hospital cardiac arrest ethical decisions

Withholding and withdrawing care in the newborn and neonate especially pre-term and low birthweight

Organ and Tissue Donation after resuscitation

Ethics of resuscitation research Ethics of training on the newly dead

CPR WIN (Whats Important Now)

90 of all changes to 2010 ECC are right in the BLS segment

Builds on and further enhances the changes and research discussed in the 2005 guidelines

COMPRESSIONS are the single most emphasized segment of resuscitation

GOOD and SUSTAINED Coronary Perfusion Pressure is the GOAL

Understanding CPP

Coronary Perfusion Pressure (CPP) is essential to ROSC

When arrest is present for more than a few minutes the myocardium is depleted of oxygen and metabolic substrates

A brief period of (good and sustained) chest compressions can deliver oxygen and energy substrates (ie ATP) increasing the likelihood that a shock may terminate VF (defibrillation) and a perfusing rhythm will return (ie ROSC)

Without this a shock may result in ldquoSECONDARY ASYSTOLErdquo

GOOD and SUSTAINED CPP results in higher levels of myocardial ATP and survival

3 Phase Model

Understanding Coronary Perfusion Pressure

Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure

ROSC Associated with CPP

Overview of ECC 2010 Changes

Hands Only CPR

Single biggest change ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons

Hands Only CPR

Of note some healthcare providers and laypersons indicate that reluctance to perform mouth-to-mouth ventilation for victims of cardiac arrest is a theoretical and potential barrier to performing bystander CPR

When actual bystanders were interviewed however such reluctance was not expressed panic was cited as the major obstacle to laypersons performance of bystander CPR

The simpler Hands-Only technique may help overcome panic and hesitation to act in both regards

KEY POINT

HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR in LAY RESCUERS

This presumes that traditional CPR with ventilation will eventually be performed

The exact interval in which hands only CPR is more beneficial over traditional CPR is not known

CAB

Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

Confusion in Agonal Respirations vs Good Respirations

The rescuer should treat the victim who has occasional gasps as if he or she is not breathing (Class ILOE C)

The HCP will combine their assessment for respirations with assessment for responsiveness

The Layperson will assume that if the patient is completely unresponsive they have ineffective respirations

A simultaneous choreographed approach Much more emphasis on the team approach and a realistic

recognition of what and how PARAMEDICS do their job

Recognition that resuscitation is not a ldquolinierrdquo process (Step A THEN Step B etc) but a simultaneous series of actions

ldquohellipin a highly specialized environment such as a critical care unit of a hospital many of the individual components of CPR (compression-ventilation-defibrillation) may be managed simultaneously This approach requires choreography among many highly-trained rescuers who work as an integrated team

In the pre-hospital setting the order of the CPR components performed by the healthcare provider may switch between a sequenced and choreographed model depending on the proficiency of the provider and the availability of resourcesrdquo

- Circulation 2010122[suppl 3]S676 ndashS684

ldquo It is reasonable for healthcare providers to tailor the sequence of rescue actions to the most likely cause of arrestrdquo

THIS MEANS NO MORE COOK-BOOK MEDICINE

New CPR Guidelines

Traditional Healthcare Version

2005 to 2010 changes

Component of CPR

2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

PULSE CHECK HCP Only HCP only Checking for ldquoDEFNITE pulserdquo

SOME THINGS REMAIN IMPORTANTSOME THINGS REMAIN IMPORTANT

RATERATE

DEPTHDEPTH

RELEASERELEASE

UNINTERRUPTEDUNINTERRUPTED

DECREASED DECREASED VENTILATIONVENTILATION

5 KEY5 KEY ASPECTSASPECTS

OFOF GOODGOOD CPRCPR

Compression Rate (at least 100 Minute)

Rate per minute is NOT a function of ldquospeedrdquo of compressions only but a function of both speed ands minimizing no-flow periods (discussed later) for a total compressionsminute

Compressions rates as high as 130 resulted in favorable outcomes

Compression rates lt87minute saw rapid drop off in ROSC

NEW RECOMMENDATION At LEAST 100minute

Better too fast than too slow

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

76

75

58

42

Compression Rate

Target = ~100min with complete release Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH (At least 2 inches)

Previous studies show that only about 27 of compressions were deep enough (Wik 2005)

0 (none) were too deep NEW GIUDELINES The adult sternum

should be depressed at least 2 inches (5 cm) (Class IIa LOE B) with chest compression and chest recoilrelaxation times approximately equal (Class IIb LOE C)

Compression DEPTH

Target = 38-51 mm with complete release Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Complete RELEASERECOIL (Full)

Complete Recoil essential to reduce intrathoracic pressure between compressions

Reducing recoil improves hemodynamics in arrest and improves Coronary Perfusion Pressure (CPP)

Incomplete chest wall recoil can be reduced during CPR by using electronic recording devices that provide real-time feedback

Niles D Nysaether J Sutton R Nishisaki A Abella BS Arbogast K Maltese MR Berg RA Helfaer M Nadkarni V Leaning is common during in-hospital

pediatric CPR and decreased with automated corrective feedback Resuscitation 200980553ndash557

Intra-thoracic Pressure and CPR

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and Recoil

Abella et al 2005 Circulation

INTURRUPTIONS

Pausing for procedures intubation IV pulse check etc)

Pausing for rhythm analysis Pausing after shock to await post-

shock rhythm Pausing to charge clear and shock Unaware of importance of CPR in

ldquobig picturerdquo

No-Flow Ratio (Interruption of CPR)

Target = less than 20 Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

KEY POINT

ldquohellipHigh-quality CPR is important not only at the onset but throughout the course of resuscitation Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPRrdquo

AHA 2010 Guidelines

DECREASING VENTILATION

CPR with Advanced Airway 8 ndash 10 breathsminute

Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

EVIDENCE BASED MEDICINE

Using material from Sayre MR OrsquoConnor RE Atkins DL Billi JE Callaway CW Shuster M Eigel B Montgomery WH Hickey RW Jacobs I Nadkarni VM Morley PT Semenko TI

Hazinski MF Part 2 evidence evaluation and management of potential or perceived conflicts of interest 2010 American Heart Association Guidelines for

Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010122(suppl 3)S657ndashS664

Levels of Evidence Used to be 7 (or 8 ) different

ILCOR levels of Evidence (LOE) In 2010 ILCOR reduced these to

5 The AHA has broken these into

three broad categories

Level A ndash Highest standard of evidence

Level B ndash Most common Level C ndash Anecdotal case reports

consensus opinions retrospective studies small studies previous standard of care without evidence to contrary

Levels of Evidence

KEY POINT

ldquo A recommendation with Level of Evidence B or C does not imply that the recommendation is weak Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials Even though randomized trials are not available there may be a very clear clinical consensus that a particular test or therapy is useful or effectiverdquo

- 2010 AHA ECC GuidelinesCirculation 2010122S657-S664

Classes of Recommendations

bull Most previous classes retained with better clarifications and descriptions

bullldquoClass Indeterminaterdquo recommendations which were used in 2005 are not included in the 2010 AHA Guidelines for CPR and ECC The elimination of the term ldquoClass Indeterminaterdquo is consistent with the ACCFndashAHA Classes of Recommendation

bullWhen the AHA writing groups felt that the evidence was insufficient to offer a recommendation either for or against the use of a drug or intervention no recommendation was given

ETHICAL CONSIDERATIONS IN ECC

Using material from

Morrison LJ Kierzek G Diekema DS Sayre MR Silvers SM Idris AH Mancini ME Part 3 ethics 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010122(suppl 3)S665ndashS675

ECC and DEATH

New TERMS DNR

DNAR Do not attempt Resuscitation AND Allow Natural Death

Principle of Futility Defined as lt1 chance of success or

positive outcome

Withholding Resuscitation

Mild changes in verbage Situations where attempts to perform CPR

would place the rescuer at risk of serious injury or mortal peril

Obvious clinical signs of irreversible death (eg rigor-mortis dependent lividity decapitation transection or decomposition)

A valid signed and dated advance directive indicating that resuscitation is not desired or a valid signed and dated DNAR order

Termination of Resuscitation- BLS when ALS is not available or delayed

All 3 of the following criteria must be present before moving to the ambulance for transport to consider terminating BLS resuscitative attempts for adult victims of out-of-hospital cardiac arrest (1)Arrest was not witnessed by EMS provider or first responder (2) No return of spontaneous circulation (ROSC) after 3 full rounds of CPR and automated external defibrillator (AED) analysis (3) and no AED shocks were deliveredThis is to be used in conjunction with consultation with real time on line medical control

(Class IIb LOE A)

Termination of Resuscitation- ALS

All 3 of the following criteria must be present before moving to the ambulance for transport to consider terminating BLS and ALS resuscitative attempts for adult victims of out-of-hospital cardiac arrest (1)Arrest was not witnessed by EMS provider or first responder (2) No return of spontaneous circulation (ROSC) after ldquofull ALS carerdquo (defined as 20 minutes of ALS and an advanced airway (3) and no AED shocks were delivered prior to ALS arrival

(Class IIa LOE B)

Why Terminate

Termination of Resuscitative Efforts and Transport Implications

Field termination reduces unnecessary transport to the hospital by 60 with the BLS rule and 40 with the ALS rule reducing associated road hazards that put the provider patient and public at risk

In addition field termination reduces inadvertent paramedic exposure to potential biohazards and the higher cost of ED pronouncement

More importantly the quality of CPR is compromised during transport and survival is linked to optimizing scene care rather than rushing to hospital

Termination of Resuscitation in Pediatrics

No predictors of neonatal or pediatric (infant or child) out-of hospital resuscitation success or failure have been established

No validated clinical decision rules have been derived and evaluated Further research in this area is needed

In the absence of clinical decision rules for the neonatal or pediatric OHCA victim the responsible prehospital provider should follow BLS pediatric and advanced cardiovascular life support protocols and consult with real-time medical direction or transport the victim to the most appropriate facility per local directives

Other Ethical Questions we did not discuss that are in the AHA documents

In hospital cardiac arrest ethical decisions

Withholding and withdrawing care in the newborn and neonate especially pre-term and low birthweight

Organ and Tissue Donation after resuscitation

Ethics of resuscitation research Ethics of training on the newly dead

CPR WIN (Whats Important Now)

90 of all changes to 2010 ECC are right in the BLS segment

Builds on and further enhances the changes and research discussed in the 2005 guidelines

COMPRESSIONS are the single most emphasized segment of resuscitation

GOOD and SUSTAINED Coronary Perfusion Pressure is the GOAL

Understanding CPP

Coronary Perfusion Pressure (CPP) is essential to ROSC

When arrest is present for more than a few minutes the myocardium is depleted of oxygen and metabolic substrates

A brief period of (good and sustained) chest compressions can deliver oxygen and energy substrates (ie ATP) increasing the likelihood that a shock may terminate VF (defibrillation) and a perfusing rhythm will return (ie ROSC)

Without this a shock may result in ldquoSECONDARY ASYSTOLErdquo

GOOD and SUSTAINED CPP results in higher levels of myocardial ATP and survival

3 Phase Model

Understanding Coronary Perfusion Pressure

Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure

ROSC Associated with CPP

Overview of ECC 2010 Changes

Hands Only CPR

Single biggest change ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons

Hands Only CPR

Of note some healthcare providers and laypersons indicate that reluctance to perform mouth-to-mouth ventilation for victims of cardiac arrest is a theoretical and potential barrier to performing bystander CPR

When actual bystanders were interviewed however such reluctance was not expressed panic was cited as the major obstacle to laypersons performance of bystander CPR

The simpler Hands-Only technique may help overcome panic and hesitation to act in both regards

KEY POINT

HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR in LAY RESCUERS

This presumes that traditional CPR with ventilation will eventually be performed

The exact interval in which hands only CPR is more beneficial over traditional CPR is not known

CAB

Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

Confusion in Agonal Respirations vs Good Respirations

The rescuer should treat the victim who has occasional gasps as if he or she is not breathing (Class ILOE C)

The HCP will combine their assessment for respirations with assessment for responsiveness

The Layperson will assume that if the patient is completely unresponsive they have ineffective respirations

A simultaneous choreographed approach Much more emphasis on the team approach and a realistic

recognition of what and how PARAMEDICS do their job

Recognition that resuscitation is not a ldquolinierrdquo process (Step A THEN Step B etc) but a simultaneous series of actions

ldquohellipin a highly specialized environment such as a critical care unit of a hospital many of the individual components of CPR (compression-ventilation-defibrillation) may be managed simultaneously This approach requires choreography among many highly-trained rescuers who work as an integrated team

In the pre-hospital setting the order of the CPR components performed by the healthcare provider may switch between a sequenced and choreographed model depending on the proficiency of the provider and the availability of resourcesrdquo

- Circulation 2010122[suppl 3]S676 ndashS684

ldquo It is reasonable for healthcare providers to tailor the sequence of rescue actions to the most likely cause of arrestrdquo

THIS MEANS NO MORE COOK-BOOK MEDICINE

New CPR Guidelines

Traditional Healthcare Version

2005 to 2010 changes

Component of CPR

2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

PULSE CHECK HCP Only HCP only Checking for ldquoDEFNITE pulserdquo

SOME THINGS REMAIN IMPORTANTSOME THINGS REMAIN IMPORTANT

RATERATE

DEPTHDEPTH

RELEASERELEASE

UNINTERRUPTEDUNINTERRUPTED

DECREASED DECREASED VENTILATIONVENTILATION

5 KEY5 KEY ASPECTSASPECTS

OFOF GOODGOOD CPRCPR

Compression Rate (at least 100 Minute)

Rate per minute is NOT a function of ldquospeedrdquo of compressions only but a function of both speed ands minimizing no-flow periods (discussed later) for a total compressionsminute

Compressions rates as high as 130 resulted in favorable outcomes

Compression rates lt87minute saw rapid drop off in ROSC

NEW RECOMMENDATION At LEAST 100minute

Better too fast than too slow

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

76

75

58

42

Compression Rate

Target = ~100min with complete release Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH (At least 2 inches)

Previous studies show that only about 27 of compressions were deep enough (Wik 2005)

0 (none) were too deep NEW GIUDELINES The adult sternum

should be depressed at least 2 inches (5 cm) (Class IIa LOE B) with chest compression and chest recoilrelaxation times approximately equal (Class IIb LOE C)

Compression DEPTH

Target = 38-51 mm with complete release Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Complete RELEASERECOIL (Full)

Complete Recoil essential to reduce intrathoracic pressure between compressions

Reducing recoil improves hemodynamics in arrest and improves Coronary Perfusion Pressure (CPP)

Incomplete chest wall recoil can be reduced during CPR by using electronic recording devices that provide real-time feedback

Niles D Nysaether J Sutton R Nishisaki A Abella BS Arbogast K Maltese MR Berg RA Helfaer M Nadkarni V Leaning is common during in-hospital

pediatric CPR and decreased with automated corrective feedback Resuscitation 200980553ndash557

Intra-thoracic Pressure and CPR

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and Recoil

Abella et al 2005 Circulation

INTURRUPTIONS

Pausing for procedures intubation IV pulse check etc)

Pausing for rhythm analysis Pausing after shock to await post-

shock rhythm Pausing to charge clear and shock Unaware of importance of CPR in

ldquobig picturerdquo

No-Flow Ratio (Interruption of CPR)

Target = less than 20 Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

KEY POINT

ldquohellipHigh-quality CPR is important not only at the onset but throughout the course of resuscitation Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPRrdquo

AHA 2010 Guidelines

DECREASING VENTILATION

CPR with Advanced Airway 8 ndash 10 breathsminute

Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Levels of Evidence Used to be 7 (or 8 ) different

ILCOR levels of Evidence (LOE) In 2010 ILCOR reduced these to

5 The AHA has broken these into

three broad categories

Level A ndash Highest standard of evidence

Level B ndash Most common Level C ndash Anecdotal case reports

consensus opinions retrospective studies small studies previous standard of care without evidence to contrary

Levels of Evidence

KEY POINT

ldquo A recommendation with Level of Evidence B or C does not imply that the recommendation is weak Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials Even though randomized trials are not available there may be a very clear clinical consensus that a particular test or therapy is useful or effectiverdquo

- 2010 AHA ECC GuidelinesCirculation 2010122S657-S664

Classes of Recommendations

bull Most previous classes retained with better clarifications and descriptions

bullldquoClass Indeterminaterdquo recommendations which were used in 2005 are not included in the 2010 AHA Guidelines for CPR and ECC The elimination of the term ldquoClass Indeterminaterdquo is consistent with the ACCFndashAHA Classes of Recommendation

bullWhen the AHA writing groups felt that the evidence was insufficient to offer a recommendation either for or against the use of a drug or intervention no recommendation was given

ETHICAL CONSIDERATIONS IN ECC

Using material from

Morrison LJ Kierzek G Diekema DS Sayre MR Silvers SM Idris AH Mancini ME Part 3 ethics 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010122(suppl 3)S665ndashS675

ECC and DEATH

New TERMS DNR

DNAR Do not attempt Resuscitation AND Allow Natural Death

Principle of Futility Defined as lt1 chance of success or

positive outcome

Withholding Resuscitation

Mild changes in verbage Situations where attempts to perform CPR

would place the rescuer at risk of serious injury or mortal peril

Obvious clinical signs of irreversible death (eg rigor-mortis dependent lividity decapitation transection or decomposition)

A valid signed and dated advance directive indicating that resuscitation is not desired or a valid signed and dated DNAR order

Termination of Resuscitation- BLS when ALS is not available or delayed

All 3 of the following criteria must be present before moving to the ambulance for transport to consider terminating BLS resuscitative attempts for adult victims of out-of-hospital cardiac arrest (1)Arrest was not witnessed by EMS provider or first responder (2) No return of spontaneous circulation (ROSC) after 3 full rounds of CPR and automated external defibrillator (AED) analysis (3) and no AED shocks were deliveredThis is to be used in conjunction with consultation with real time on line medical control

(Class IIb LOE A)

Termination of Resuscitation- ALS

All 3 of the following criteria must be present before moving to the ambulance for transport to consider terminating BLS and ALS resuscitative attempts for adult victims of out-of-hospital cardiac arrest (1)Arrest was not witnessed by EMS provider or first responder (2) No return of spontaneous circulation (ROSC) after ldquofull ALS carerdquo (defined as 20 minutes of ALS and an advanced airway (3) and no AED shocks were delivered prior to ALS arrival

(Class IIa LOE B)

Why Terminate

Termination of Resuscitative Efforts and Transport Implications

Field termination reduces unnecessary transport to the hospital by 60 with the BLS rule and 40 with the ALS rule reducing associated road hazards that put the provider patient and public at risk

In addition field termination reduces inadvertent paramedic exposure to potential biohazards and the higher cost of ED pronouncement

More importantly the quality of CPR is compromised during transport and survival is linked to optimizing scene care rather than rushing to hospital

Termination of Resuscitation in Pediatrics

No predictors of neonatal or pediatric (infant or child) out-of hospital resuscitation success or failure have been established

No validated clinical decision rules have been derived and evaluated Further research in this area is needed

In the absence of clinical decision rules for the neonatal or pediatric OHCA victim the responsible prehospital provider should follow BLS pediatric and advanced cardiovascular life support protocols and consult with real-time medical direction or transport the victim to the most appropriate facility per local directives

Other Ethical Questions we did not discuss that are in the AHA documents

In hospital cardiac arrest ethical decisions

Withholding and withdrawing care in the newborn and neonate especially pre-term and low birthweight

Organ and Tissue Donation after resuscitation

Ethics of resuscitation research Ethics of training on the newly dead

CPR WIN (Whats Important Now)

90 of all changes to 2010 ECC are right in the BLS segment

Builds on and further enhances the changes and research discussed in the 2005 guidelines

COMPRESSIONS are the single most emphasized segment of resuscitation

GOOD and SUSTAINED Coronary Perfusion Pressure is the GOAL

Understanding CPP

Coronary Perfusion Pressure (CPP) is essential to ROSC

When arrest is present for more than a few minutes the myocardium is depleted of oxygen and metabolic substrates

A brief period of (good and sustained) chest compressions can deliver oxygen and energy substrates (ie ATP) increasing the likelihood that a shock may terminate VF (defibrillation) and a perfusing rhythm will return (ie ROSC)

Without this a shock may result in ldquoSECONDARY ASYSTOLErdquo

GOOD and SUSTAINED CPP results in higher levels of myocardial ATP and survival

3 Phase Model

Understanding Coronary Perfusion Pressure

Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure

ROSC Associated with CPP

Overview of ECC 2010 Changes

Hands Only CPR

Single biggest change ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons

Hands Only CPR

Of note some healthcare providers and laypersons indicate that reluctance to perform mouth-to-mouth ventilation for victims of cardiac arrest is a theoretical and potential barrier to performing bystander CPR

When actual bystanders were interviewed however such reluctance was not expressed panic was cited as the major obstacle to laypersons performance of bystander CPR

The simpler Hands-Only technique may help overcome panic and hesitation to act in both regards

KEY POINT

HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR in LAY RESCUERS

This presumes that traditional CPR with ventilation will eventually be performed

The exact interval in which hands only CPR is more beneficial over traditional CPR is not known

CAB

Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

Confusion in Agonal Respirations vs Good Respirations

The rescuer should treat the victim who has occasional gasps as if he or she is not breathing (Class ILOE C)

The HCP will combine their assessment for respirations with assessment for responsiveness

The Layperson will assume that if the patient is completely unresponsive they have ineffective respirations

A simultaneous choreographed approach Much more emphasis on the team approach and a realistic

recognition of what and how PARAMEDICS do their job

Recognition that resuscitation is not a ldquolinierrdquo process (Step A THEN Step B etc) but a simultaneous series of actions

ldquohellipin a highly specialized environment such as a critical care unit of a hospital many of the individual components of CPR (compression-ventilation-defibrillation) may be managed simultaneously This approach requires choreography among many highly-trained rescuers who work as an integrated team

In the pre-hospital setting the order of the CPR components performed by the healthcare provider may switch between a sequenced and choreographed model depending on the proficiency of the provider and the availability of resourcesrdquo

- Circulation 2010122[suppl 3]S676 ndashS684

ldquo It is reasonable for healthcare providers to tailor the sequence of rescue actions to the most likely cause of arrestrdquo

THIS MEANS NO MORE COOK-BOOK MEDICINE

New CPR Guidelines

Traditional Healthcare Version

2005 to 2010 changes

Component of CPR

2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

PULSE CHECK HCP Only HCP only Checking for ldquoDEFNITE pulserdquo

SOME THINGS REMAIN IMPORTANTSOME THINGS REMAIN IMPORTANT

RATERATE

DEPTHDEPTH

RELEASERELEASE

UNINTERRUPTEDUNINTERRUPTED

DECREASED DECREASED VENTILATIONVENTILATION

5 KEY5 KEY ASPECTSASPECTS

OFOF GOODGOOD CPRCPR

Compression Rate (at least 100 Minute)

Rate per minute is NOT a function of ldquospeedrdquo of compressions only but a function of both speed ands minimizing no-flow periods (discussed later) for a total compressionsminute

Compressions rates as high as 130 resulted in favorable outcomes

Compression rates lt87minute saw rapid drop off in ROSC

NEW RECOMMENDATION At LEAST 100minute

Better too fast than too slow

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

76

75

58

42

Compression Rate

Target = ~100min with complete release Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH (At least 2 inches)

Previous studies show that only about 27 of compressions were deep enough (Wik 2005)

0 (none) were too deep NEW GIUDELINES The adult sternum

should be depressed at least 2 inches (5 cm) (Class IIa LOE B) with chest compression and chest recoilrelaxation times approximately equal (Class IIb LOE C)

Compression DEPTH

Target = 38-51 mm with complete release Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Complete RELEASERECOIL (Full)

Complete Recoil essential to reduce intrathoracic pressure between compressions

Reducing recoil improves hemodynamics in arrest and improves Coronary Perfusion Pressure (CPP)

Incomplete chest wall recoil can be reduced during CPR by using electronic recording devices that provide real-time feedback

Niles D Nysaether J Sutton R Nishisaki A Abella BS Arbogast K Maltese MR Berg RA Helfaer M Nadkarni V Leaning is common during in-hospital

pediatric CPR and decreased with automated corrective feedback Resuscitation 200980553ndash557

Intra-thoracic Pressure and CPR

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and Recoil

Abella et al 2005 Circulation

INTURRUPTIONS

Pausing for procedures intubation IV pulse check etc)

Pausing for rhythm analysis Pausing after shock to await post-

shock rhythm Pausing to charge clear and shock Unaware of importance of CPR in

ldquobig picturerdquo

No-Flow Ratio (Interruption of CPR)

Target = less than 20 Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

KEY POINT

ldquohellipHigh-quality CPR is important not only at the onset but throughout the course of resuscitation Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPRrdquo

AHA 2010 Guidelines

DECREASING VENTILATION

CPR with Advanced Airway 8 ndash 10 breathsminute

Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Levels of Evidence

KEY POINT

ldquo A recommendation with Level of Evidence B or C does not imply that the recommendation is weak Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials Even though randomized trials are not available there may be a very clear clinical consensus that a particular test or therapy is useful or effectiverdquo

- 2010 AHA ECC GuidelinesCirculation 2010122S657-S664

Classes of Recommendations

bull Most previous classes retained with better clarifications and descriptions

bullldquoClass Indeterminaterdquo recommendations which were used in 2005 are not included in the 2010 AHA Guidelines for CPR and ECC The elimination of the term ldquoClass Indeterminaterdquo is consistent with the ACCFndashAHA Classes of Recommendation

bullWhen the AHA writing groups felt that the evidence was insufficient to offer a recommendation either for or against the use of a drug or intervention no recommendation was given

ETHICAL CONSIDERATIONS IN ECC

Using material from

Morrison LJ Kierzek G Diekema DS Sayre MR Silvers SM Idris AH Mancini ME Part 3 ethics 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010122(suppl 3)S665ndashS675

ECC and DEATH

New TERMS DNR

DNAR Do not attempt Resuscitation AND Allow Natural Death

Principle of Futility Defined as lt1 chance of success or

positive outcome

Withholding Resuscitation

Mild changes in verbage Situations where attempts to perform CPR

would place the rescuer at risk of serious injury or mortal peril

Obvious clinical signs of irreversible death (eg rigor-mortis dependent lividity decapitation transection or decomposition)

A valid signed and dated advance directive indicating that resuscitation is not desired or a valid signed and dated DNAR order

Termination of Resuscitation- BLS when ALS is not available or delayed

All 3 of the following criteria must be present before moving to the ambulance for transport to consider terminating BLS resuscitative attempts for adult victims of out-of-hospital cardiac arrest (1)Arrest was not witnessed by EMS provider or first responder (2) No return of spontaneous circulation (ROSC) after 3 full rounds of CPR and automated external defibrillator (AED) analysis (3) and no AED shocks were deliveredThis is to be used in conjunction with consultation with real time on line medical control

(Class IIb LOE A)

Termination of Resuscitation- ALS

All 3 of the following criteria must be present before moving to the ambulance for transport to consider terminating BLS and ALS resuscitative attempts for adult victims of out-of-hospital cardiac arrest (1)Arrest was not witnessed by EMS provider or first responder (2) No return of spontaneous circulation (ROSC) after ldquofull ALS carerdquo (defined as 20 minutes of ALS and an advanced airway (3) and no AED shocks were delivered prior to ALS arrival

(Class IIa LOE B)

Why Terminate

Termination of Resuscitative Efforts and Transport Implications

Field termination reduces unnecessary transport to the hospital by 60 with the BLS rule and 40 with the ALS rule reducing associated road hazards that put the provider patient and public at risk

In addition field termination reduces inadvertent paramedic exposure to potential biohazards and the higher cost of ED pronouncement

More importantly the quality of CPR is compromised during transport and survival is linked to optimizing scene care rather than rushing to hospital

Termination of Resuscitation in Pediatrics

No predictors of neonatal or pediatric (infant or child) out-of hospital resuscitation success or failure have been established

No validated clinical decision rules have been derived and evaluated Further research in this area is needed

In the absence of clinical decision rules for the neonatal or pediatric OHCA victim the responsible prehospital provider should follow BLS pediatric and advanced cardiovascular life support protocols and consult with real-time medical direction or transport the victim to the most appropriate facility per local directives

Other Ethical Questions we did not discuss that are in the AHA documents

In hospital cardiac arrest ethical decisions

Withholding and withdrawing care in the newborn and neonate especially pre-term and low birthweight

Organ and Tissue Donation after resuscitation

Ethics of resuscitation research Ethics of training on the newly dead

CPR WIN (Whats Important Now)

90 of all changes to 2010 ECC are right in the BLS segment

Builds on and further enhances the changes and research discussed in the 2005 guidelines

COMPRESSIONS are the single most emphasized segment of resuscitation

GOOD and SUSTAINED Coronary Perfusion Pressure is the GOAL

Understanding CPP

Coronary Perfusion Pressure (CPP) is essential to ROSC

When arrest is present for more than a few minutes the myocardium is depleted of oxygen and metabolic substrates

A brief period of (good and sustained) chest compressions can deliver oxygen and energy substrates (ie ATP) increasing the likelihood that a shock may terminate VF (defibrillation) and a perfusing rhythm will return (ie ROSC)

Without this a shock may result in ldquoSECONDARY ASYSTOLErdquo

GOOD and SUSTAINED CPP results in higher levels of myocardial ATP and survival

3 Phase Model

Understanding Coronary Perfusion Pressure

Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure

ROSC Associated with CPP

Overview of ECC 2010 Changes

Hands Only CPR

Single biggest change ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons

Hands Only CPR

Of note some healthcare providers and laypersons indicate that reluctance to perform mouth-to-mouth ventilation for victims of cardiac arrest is a theoretical and potential barrier to performing bystander CPR

When actual bystanders were interviewed however such reluctance was not expressed panic was cited as the major obstacle to laypersons performance of bystander CPR

The simpler Hands-Only technique may help overcome panic and hesitation to act in both regards

KEY POINT

HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR in LAY RESCUERS

This presumes that traditional CPR with ventilation will eventually be performed

The exact interval in which hands only CPR is more beneficial over traditional CPR is not known

CAB

Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

Confusion in Agonal Respirations vs Good Respirations

The rescuer should treat the victim who has occasional gasps as if he or she is not breathing (Class ILOE C)

The HCP will combine their assessment for respirations with assessment for responsiveness

The Layperson will assume that if the patient is completely unresponsive they have ineffective respirations

A simultaneous choreographed approach Much more emphasis on the team approach and a realistic

recognition of what and how PARAMEDICS do their job

Recognition that resuscitation is not a ldquolinierrdquo process (Step A THEN Step B etc) but a simultaneous series of actions

ldquohellipin a highly specialized environment such as a critical care unit of a hospital many of the individual components of CPR (compression-ventilation-defibrillation) may be managed simultaneously This approach requires choreography among many highly-trained rescuers who work as an integrated team

In the pre-hospital setting the order of the CPR components performed by the healthcare provider may switch between a sequenced and choreographed model depending on the proficiency of the provider and the availability of resourcesrdquo

- Circulation 2010122[suppl 3]S676 ndashS684

ldquo It is reasonable for healthcare providers to tailor the sequence of rescue actions to the most likely cause of arrestrdquo

THIS MEANS NO MORE COOK-BOOK MEDICINE

New CPR Guidelines

Traditional Healthcare Version

2005 to 2010 changes

Component of CPR

2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

PULSE CHECK HCP Only HCP only Checking for ldquoDEFNITE pulserdquo

SOME THINGS REMAIN IMPORTANTSOME THINGS REMAIN IMPORTANT

RATERATE

DEPTHDEPTH

RELEASERELEASE

UNINTERRUPTEDUNINTERRUPTED

DECREASED DECREASED VENTILATIONVENTILATION

5 KEY5 KEY ASPECTSASPECTS

OFOF GOODGOOD CPRCPR

Compression Rate (at least 100 Minute)

Rate per minute is NOT a function of ldquospeedrdquo of compressions only but a function of both speed ands minimizing no-flow periods (discussed later) for a total compressionsminute

Compressions rates as high as 130 resulted in favorable outcomes

Compression rates lt87minute saw rapid drop off in ROSC

NEW RECOMMENDATION At LEAST 100minute

Better too fast than too slow

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

76

75

58

42

Compression Rate

Target = ~100min with complete release Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH (At least 2 inches)

Previous studies show that only about 27 of compressions were deep enough (Wik 2005)

0 (none) were too deep NEW GIUDELINES The adult sternum

should be depressed at least 2 inches (5 cm) (Class IIa LOE B) with chest compression and chest recoilrelaxation times approximately equal (Class IIb LOE C)

Compression DEPTH

Target = 38-51 mm with complete release Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Complete RELEASERECOIL (Full)

Complete Recoil essential to reduce intrathoracic pressure between compressions

Reducing recoil improves hemodynamics in arrest and improves Coronary Perfusion Pressure (CPP)

Incomplete chest wall recoil can be reduced during CPR by using electronic recording devices that provide real-time feedback

Niles D Nysaether J Sutton R Nishisaki A Abella BS Arbogast K Maltese MR Berg RA Helfaer M Nadkarni V Leaning is common during in-hospital

pediatric CPR and decreased with automated corrective feedback Resuscitation 200980553ndash557

Intra-thoracic Pressure and CPR

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and Recoil

Abella et al 2005 Circulation

INTURRUPTIONS

Pausing for procedures intubation IV pulse check etc)

Pausing for rhythm analysis Pausing after shock to await post-

shock rhythm Pausing to charge clear and shock Unaware of importance of CPR in

ldquobig picturerdquo

No-Flow Ratio (Interruption of CPR)

Target = less than 20 Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

KEY POINT

ldquohellipHigh-quality CPR is important not only at the onset but throughout the course of resuscitation Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPRrdquo

AHA 2010 Guidelines

DECREASING VENTILATION

CPR with Advanced Airway 8 ndash 10 breathsminute

Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

KEY POINT

ldquo A recommendation with Level of Evidence B or C does not imply that the recommendation is weak Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials Even though randomized trials are not available there may be a very clear clinical consensus that a particular test or therapy is useful or effectiverdquo

- 2010 AHA ECC GuidelinesCirculation 2010122S657-S664

Classes of Recommendations

bull Most previous classes retained with better clarifications and descriptions

bullldquoClass Indeterminaterdquo recommendations which were used in 2005 are not included in the 2010 AHA Guidelines for CPR and ECC The elimination of the term ldquoClass Indeterminaterdquo is consistent with the ACCFndashAHA Classes of Recommendation

bullWhen the AHA writing groups felt that the evidence was insufficient to offer a recommendation either for or against the use of a drug or intervention no recommendation was given

ETHICAL CONSIDERATIONS IN ECC

Using material from

Morrison LJ Kierzek G Diekema DS Sayre MR Silvers SM Idris AH Mancini ME Part 3 ethics 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010122(suppl 3)S665ndashS675

ECC and DEATH

New TERMS DNR

DNAR Do not attempt Resuscitation AND Allow Natural Death

Principle of Futility Defined as lt1 chance of success or

positive outcome

Withholding Resuscitation

Mild changes in verbage Situations where attempts to perform CPR

would place the rescuer at risk of serious injury or mortal peril

Obvious clinical signs of irreversible death (eg rigor-mortis dependent lividity decapitation transection or decomposition)

A valid signed and dated advance directive indicating that resuscitation is not desired or a valid signed and dated DNAR order

Termination of Resuscitation- BLS when ALS is not available or delayed

All 3 of the following criteria must be present before moving to the ambulance for transport to consider terminating BLS resuscitative attempts for adult victims of out-of-hospital cardiac arrest (1)Arrest was not witnessed by EMS provider or first responder (2) No return of spontaneous circulation (ROSC) after 3 full rounds of CPR and automated external defibrillator (AED) analysis (3) and no AED shocks were deliveredThis is to be used in conjunction with consultation with real time on line medical control

(Class IIb LOE A)

Termination of Resuscitation- ALS

All 3 of the following criteria must be present before moving to the ambulance for transport to consider terminating BLS and ALS resuscitative attempts for adult victims of out-of-hospital cardiac arrest (1)Arrest was not witnessed by EMS provider or first responder (2) No return of spontaneous circulation (ROSC) after ldquofull ALS carerdquo (defined as 20 minutes of ALS and an advanced airway (3) and no AED shocks were delivered prior to ALS arrival

(Class IIa LOE B)

Why Terminate

Termination of Resuscitative Efforts and Transport Implications

Field termination reduces unnecessary transport to the hospital by 60 with the BLS rule and 40 with the ALS rule reducing associated road hazards that put the provider patient and public at risk

In addition field termination reduces inadvertent paramedic exposure to potential biohazards and the higher cost of ED pronouncement

More importantly the quality of CPR is compromised during transport and survival is linked to optimizing scene care rather than rushing to hospital

Termination of Resuscitation in Pediatrics

No predictors of neonatal or pediatric (infant or child) out-of hospital resuscitation success or failure have been established

No validated clinical decision rules have been derived and evaluated Further research in this area is needed

In the absence of clinical decision rules for the neonatal or pediatric OHCA victim the responsible prehospital provider should follow BLS pediatric and advanced cardiovascular life support protocols and consult with real-time medical direction or transport the victim to the most appropriate facility per local directives

Other Ethical Questions we did not discuss that are in the AHA documents

In hospital cardiac arrest ethical decisions

Withholding and withdrawing care in the newborn and neonate especially pre-term and low birthweight

Organ and Tissue Donation after resuscitation

Ethics of resuscitation research Ethics of training on the newly dead

CPR WIN (Whats Important Now)

90 of all changes to 2010 ECC are right in the BLS segment

Builds on and further enhances the changes and research discussed in the 2005 guidelines

COMPRESSIONS are the single most emphasized segment of resuscitation

GOOD and SUSTAINED Coronary Perfusion Pressure is the GOAL

Understanding CPP

Coronary Perfusion Pressure (CPP) is essential to ROSC

When arrest is present for more than a few minutes the myocardium is depleted of oxygen and metabolic substrates

A brief period of (good and sustained) chest compressions can deliver oxygen and energy substrates (ie ATP) increasing the likelihood that a shock may terminate VF (defibrillation) and a perfusing rhythm will return (ie ROSC)

Without this a shock may result in ldquoSECONDARY ASYSTOLErdquo

GOOD and SUSTAINED CPP results in higher levels of myocardial ATP and survival

3 Phase Model

Understanding Coronary Perfusion Pressure

Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure

ROSC Associated with CPP

Overview of ECC 2010 Changes

Hands Only CPR

Single biggest change ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons

Hands Only CPR

Of note some healthcare providers and laypersons indicate that reluctance to perform mouth-to-mouth ventilation for victims of cardiac arrest is a theoretical and potential barrier to performing bystander CPR

When actual bystanders were interviewed however such reluctance was not expressed panic was cited as the major obstacle to laypersons performance of bystander CPR

The simpler Hands-Only technique may help overcome panic and hesitation to act in both regards

KEY POINT

HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR in LAY RESCUERS

This presumes that traditional CPR with ventilation will eventually be performed

The exact interval in which hands only CPR is more beneficial over traditional CPR is not known

CAB

Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

Confusion in Agonal Respirations vs Good Respirations

The rescuer should treat the victim who has occasional gasps as if he or she is not breathing (Class ILOE C)

The HCP will combine their assessment for respirations with assessment for responsiveness

The Layperson will assume that if the patient is completely unresponsive they have ineffective respirations

A simultaneous choreographed approach Much more emphasis on the team approach and a realistic

recognition of what and how PARAMEDICS do their job

Recognition that resuscitation is not a ldquolinierrdquo process (Step A THEN Step B etc) but a simultaneous series of actions

ldquohellipin a highly specialized environment such as a critical care unit of a hospital many of the individual components of CPR (compression-ventilation-defibrillation) may be managed simultaneously This approach requires choreography among many highly-trained rescuers who work as an integrated team

In the pre-hospital setting the order of the CPR components performed by the healthcare provider may switch between a sequenced and choreographed model depending on the proficiency of the provider and the availability of resourcesrdquo

- Circulation 2010122[suppl 3]S676 ndashS684

ldquo It is reasonable for healthcare providers to tailor the sequence of rescue actions to the most likely cause of arrestrdquo

THIS MEANS NO MORE COOK-BOOK MEDICINE

New CPR Guidelines

Traditional Healthcare Version

2005 to 2010 changes

Component of CPR

2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

PULSE CHECK HCP Only HCP only Checking for ldquoDEFNITE pulserdquo

SOME THINGS REMAIN IMPORTANTSOME THINGS REMAIN IMPORTANT

RATERATE

DEPTHDEPTH

RELEASERELEASE

UNINTERRUPTEDUNINTERRUPTED

DECREASED DECREASED VENTILATIONVENTILATION

5 KEY5 KEY ASPECTSASPECTS

OFOF GOODGOOD CPRCPR

Compression Rate (at least 100 Minute)

Rate per minute is NOT a function of ldquospeedrdquo of compressions only but a function of both speed ands minimizing no-flow periods (discussed later) for a total compressionsminute

Compressions rates as high as 130 resulted in favorable outcomes

Compression rates lt87minute saw rapid drop off in ROSC

NEW RECOMMENDATION At LEAST 100minute

Better too fast than too slow

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

76

75

58

42

Compression Rate

Target = ~100min with complete release Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH (At least 2 inches)

Previous studies show that only about 27 of compressions were deep enough (Wik 2005)

0 (none) were too deep NEW GIUDELINES The adult sternum

should be depressed at least 2 inches (5 cm) (Class IIa LOE B) with chest compression and chest recoilrelaxation times approximately equal (Class IIb LOE C)

Compression DEPTH

Target = 38-51 mm with complete release Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Complete RELEASERECOIL (Full)

Complete Recoil essential to reduce intrathoracic pressure between compressions

Reducing recoil improves hemodynamics in arrest and improves Coronary Perfusion Pressure (CPP)

Incomplete chest wall recoil can be reduced during CPR by using electronic recording devices that provide real-time feedback

Niles D Nysaether J Sutton R Nishisaki A Abella BS Arbogast K Maltese MR Berg RA Helfaer M Nadkarni V Leaning is common during in-hospital

pediatric CPR and decreased with automated corrective feedback Resuscitation 200980553ndash557

Intra-thoracic Pressure and CPR

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and Recoil

Abella et al 2005 Circulation

INTURRUPTIONS

Pausing for procedures intubation IV pulse check etc)

Pausing for rhythm analysis Pausing after shock to await post-

shock rhythm Pausing to charge clear and shock Unaware of importance of CPR in

ldquobig picturerdquo

No-Flow Ratio (Interruption of CPR)

Target = less than 20 Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

KEY POINT

ldquohellipHigh-quality CPR is important not only at the onset but throughout the course of resuscitation Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPRrdquo

AHA 2010 Guidelines

DECREASING VENTILATION

CPR with Advanced Airway 8 ndash 10 breathsminute

Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Classes of Recommendations

bull Most previous classes retained with better clarifications and descriptions

bullldquoClass Indeterminaterdquo recommendations which were used in 2005 are not included in the 2010 AHA Guidelines for CPR and ECC The elimination of the term ldquoClass Indeterminaterdquo is consistent with the ACCFndashAHA Classes of Recommendation

bullWhen the AHA writing groups felt that the evidence was insufficient to offer a recommendation either for or against the use of a drug or intervention no recommendation was given

ETHICAL CONSIDERATIONS IN ECC

Using material from

Morrison LJ Kierzek G Diekema DS Sayre MR Silvers SM Idris AH Mancini ME Part 3 ethics 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010122(suppl 3)S665ndashS675

ECC and DEATH

New TERMS DNR

DNAR Do not attempt Resuscitation AND Allow Natural Death

Principle of Futility Defined as lt1 chance of success or

positive outcome

Withholding Resuscitation

Mild changes in verbage Situations where attempts to perform CPR

would place the rescuer at risk of serious injury or mortal peril

Obvious clinical signs of irreversible death (eg rigor-mortis dependent lividity decapitation transection or decomposition)

A valid signed and dated advance directive indicating that resuscitation is not desired or a valid signed and dated DNAR order

Termination of Resuscitation- BLS when ALS is not available or delayed

All 3 of the following criteria must be present before moving to the ambulance for transport to consider terminating BLS resuscitative attempts for adult victims of out-of-hospital cardiac arrest (1)Arrest was not witnessed by EMS provider or first responder (2) No return of spontaneous circulation (ROSC) after 3 full rounds of CPR and automated external defibrillator (AED) analysis (3) and no AED shocks were deliveredThis is to be used in conjunction with consultation with real time on line medical control

(Class IIb LOE A)

Termination of Resuscitation- ALS

All 3 of the following criteria must be present before moving to the ambulance for transport to consider terminating BLS and ALS resuscitative attempts for adult victims of out-of-hospital cardiac arrest (1)Arrest was not witnessed by EMS provider or first responder (2) No return of spontaneous circulation (ROSC) after ldquofull ALS carerdquo (defined as 20 minutes of ALS and an advanced airway (3) and no AED shocks were delivered prior to ALS arrival

(Class IIa LOE B)

Why Terminate

Termination of Resuscitative Efforts and Transport Implications

Field termination reduces unnecessary transport to the hospital by 60 with the BLS rule and 40 with the ALS rule reducing associated road hazards that put the provider patient and public at risk

In addition field termination reduces inadvertent paramedic exposure to potential biohazards and the higher cost of ED pronouncement

More importantly the quality of CPR is compromised during transport and survival is linked to optimizing scene care rather than rushing to hospital

Termination of Resuscitation in Pediatrics

No predictors of neonatal or pediatric (infant or child) out-of hospital resuscitation success or failure have been established

No validated clinical decision rules have been derived and evaluated Further research in this area is needed

In the absence of clinical decision rules for the neonatal or pediatric OHCA victim the responsible prehospital provider should follow BLS pediatric and advanced cardiovascular life support protocols and consult with real-time medical direction or transport the victim to the most appropriate facility per local directives

Other Ethical Questions we did not discuss that are in the AHA documents

In hospital cardiac arrest ethical decisions

Withholding and withdrawing care in the newborn and neonate especially pre-term and low birthweight

Organ and Tissue Donation after resuscitation

Ethics of resuscitation research Ethics of training on the newly dead

CPR WIN (Whats Important Now)

90 of all changes to 2010 ECC are right in the BLS segment

Builds on and further enhances the changes and research discussed in the 2005 guidelines

COMPRESSIONS are the single most emphasized segment of resuscitation

GOOD and SUSTAINED Coronary Perfusion Pressure is the GOAL

Understanding CPP

Coronary Perfusion Pressure (CPP) is essential to ROSC

When arrest is present for more than a few minutes the myocardium is depleted of oxygen and metabolic substrates

A brief period of (good and sustained) chest compressions can deliver oxygen and energy substrates (ie ATP) increasing the likelihood that a shock may terminate VF (defibrillation) and a perfusing rhythm will return (ie ROSC)

Without this a shock may result in ldquoSECONDARY ASYSTOLErdquo

GOOD and SUSTAINED CPP results in higher levels of myocardial ATP and survival

3 Phase Model

Understanding Coronary Perfusion Pressure

Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure

ROSC Associated with CPP

Overview of ECC 2010 Changes

Hands Only CPR

Single biggest change ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons

Hands Only CPR

Of note some healthcare providers and laypersons indicate that reluctance to perform mouth-to-mouth ventilation for victims of cardiac arrest is a theoretical and potential barrier to performing bystander CPR

When actual bystanders were interviewed however such reluctance was not expressed panic was cited as the major obstacle to laypersons performance of bystander CPR

The simpler Hands-Only technique may help overcome panic and hesitation to act in both regards

KEY POINT

HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR in LAY RESCUERS

This presumes that traditional CPR with ventilation will eventually be performed

The exact interval in which hands only CPR is more beneficial over traditional CPR is not known

CAB

Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

Confusion in Agonal Respirations vs Good Respirations

The rescuer should treat the victim who has occasional gasps as if he or she is not breathing (Class ILOE C)

The HCP will combine their assessment for respirations with assessment for responsiveness

The Layperson will assume that if the patient is completely unresponsive they have ineffective respirations

A simultaneous choreographed approach Much more emphasis on the team approach and a realistic

recognition of what and how PARAMEDICS do their job

Recognition that resuscitation is not a ldquolinierrdquo process (Step A THEN Step B etc) but a simultaneous series of actions

ldquohellipin a highly specialized environment such as a critical care unit of a hospital many of the individual components of CPR (compression-ventilation-defibrillation) may be managed simultaneously This approach requires choreography among many highly-trained rescuers who work as an integrated team

In the pre-hospital setting the order of the CPR components performed by the healthcare provider may switch between a sequenced and choreographed model depending on the proficiency of the provider and the availability of resourcesrdquo

- Circulation 2010122[suppl 3]S676 ndashS684

ldquo It is reasonable for healthcare providers to tailor the sequence of rescue actions to the most likely cause of arrestrdquo

THIS MEANS NO MORE COOK-BOOK MEDICINE

New CPR Guidelines

Traditional Healthcare Version

2005 to 2010 changes

Component of CPR

2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

PULSE CHECK HCP Only HCP only Checking for ldquoDEFNITE pulserdquo

SOME THINGS REMAIN IMPORTANTSOME THINGS REMAIN IMPORTANT

RATERATE

DEPTHDEPTH

RELEASERELEASE

UNINTERRUPTEDUNINTERRUPTED

DECREASED DECREASED VENTILATIONVENTILATION

5 KEY5 KEY ASPECTSASPECTS

OFOF GOODGOOD CPRCPR

Compression Rate (at least 100 Minute)

Rate per minute is NOT a function of ldquospeedrdquo of compressions only but a function of both speed ands minimizing no-flow periods (discussed later) for a total compressionsminute

Compressions rates as high as 130 resulted in favorable outcomes

Compression rates lt87minute saw rapid drop off in ROSC

NEW RECOMMENDATION At LEAST 100minute

Better too fast than too slow

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

76

75

58

42

Compression Rate

Target = ~100min with complete release Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH (At least 2 inches)

Previous studies show that only about 27 of compressions were deep enough (Wik 2005)

0 (none) were too deep NEW GIUDELINES The adult sternum

should be depressed at least 2 inches (5 cm) (Class IIa LOE B) with chest compression and chest recoilrelaxation times approximately equal (Class IIb LOE C)

Compression DEPTH

Target = 38-51 mm with complete release Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Complete RELEASERECOIL (Full)

Complete Recoil essential to reduce intrathoracic pressure between compressions

Reducing recoil improves hemodynamics in arrest and improves Coronary Perfusion Pressure (CPP)

Incomplete chest wall recoil can be reduced during CPR by using electronic recording devices that provide real-time feedback

Niles D Nysaether J Sutton R Nishisaki A Abella BS Arbogast K Maltese MR Berg RA Helfaer M Nadkarni V Leaning is common during in-hospital

pediatric CPR and decreased with automated corrective feedback Resuscitation 200980553ndash557

Intra-thoracic Pressure and CPR

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and Recoil

Abella et al 2005 Circulation

INTURRUPTIONS

Pausing for procedures intubation IV pulse check etc)

Pausing for rhythm analysis Pausing after shock to await post-

shock rhythm Pausing to charge clear and shock Unaware of importance of CPR in

ldquobig picturerdquo

No-Flow Ratio (Interruption of CPR)

Target = less than 20 Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

KEY POINT

ldquohellipHigh-quality CPR is important not only at the onset but throughout the course of resuscitation Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPRrdquo

AHA 2010 Guidelines

DECREASING VENTILATION

CPR with Advanced Airway 8 ndash 10 breathsminute

Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

ETHICAL CONSIDERATIONS IN ECC

Using material from

Morrison LJ Kierzek G Diekema DS Sayre MR Silvers SM Idris AH Mancini ME Part 3 ethics 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010122(suppl 3)S665ndashS675

ECC and DEATH

New TERMS DNR

DNAR Do not attempt Resuscitation AND Allow Natural Death

Principle of Futility Defined as lt1 chance of success or

positive outcome

Withholding Resuscitation

Mild changes in verbage Situations where attempts to perform CPR

would place the rescuer at risk of serious injury or mortal peril

Obvious clinical signs of irreversible death (eg rigor-mortis dependent lividity decapitation transection or decomposition)

A valid signed and dated advance directive indicating that resuscitation is not desired or a valid signed and dated DNAR order

Termination of Resuscitation- BLS when ALS is not available or delayed

All 3 of the following criteria must be present before moving to the ambulance for transport to consider terminating BLS resuscitative attempts for adult victims of out-of-hospital cardiac arrest (1)Arrest was not witnessed by EMS provider or first responder (2) No return of spontaneous circulation (ROSC) after 3 full rounds of CPR and automated external defibrillator (AED) analysis (3) and no AED shocks were deliveredThis is to be used in conjunction with consultation with real time on line medical control

(Class IIb LOE A)

Termination of Resuscitation- ALS

All 3 of the following criteria must be present before moving to the ambulance for transport to consider terminating BLS and ALS resuscitative attempts for adult victims of out-of-hospital cardiac arrest (1)Arrest was not witnessed by EMS provider or first responder (2) No return of spontaneous circulation (ROSC) after ldquofull ALS carerdquo (defined as 20 minutes of ALS and an advanced airway (3) and no AED shocks were delivered prior to ALS arrival

(Class IIa LOE B)

Why Terminate

Termination of Resuscitative Efforts and Transport Implications

Field termination reduces unnecessary transport to the hospital by 60 with the BLS rule and 40 with the ALS rule reducing associated road hazards that put the provider patient and public at risk

In addition field termination reduces inadvertent paramedic exposure to potential biohazards and the higher cost of ED pronouncement

More importantly the quality of CPR is compromised during transport and survival is linked to optimizing scene care rather than rushing to hospital

Termination of Resuscitation in Pediatrics

No predictors of neonatal or pediatric (infant or child) out-of hospital resuscitation success or failure have been established

No validated clinical decision rules have been derived and evaluated Further research in this area is needed

In the absence of clinical decision rules for the neonatal or pediatric OHCA victim the responsible prehospital provider should follow BLS pediatric and advanced cardiovascular life support protocols and consult with real-time medical direction or transport the victim to the most appropriate facility per local directives

Other Ethical Questions we did not discuss that are in the AHA documents

In hospital cardiac arrest ethical decisions

Withholding and withdrawing care in the newborn and neonate especially pre-term and low birthweight

Organ and Tissue Donation after resuscitation

Ethics of resuscitation research Ethics of training on the newly dead

CPR WIN (Whats Important Now)

90 of all changes to 2010 ECC are right in the BLS segment

Builds on and further enhances the changes and research discussed in the 2005 guidelines

COMPRESSIONS are the single most emphasized segment of resuscitation

GOOD and SUSTAINED Coronary Perfusion Pressure is the GOAL

Understanding CPP

Coronary Perfusion Pressure (CPP) is essential to ROSC

When arrest is present for more than a few minutes the myocardium is depleted of oxygen and metabolic substrates

A brief period of (good and sustained) chest compressions can deliver oxygen and energy substrates (ie ATP) increasing the likelihood that a shock may terminate VF (defibrillation) and a perfusing rhythm will return (ie ROSC)

Without this a shock may result in ldquoSECONDARY ASYSTOLErdquo

GOOD and SUSTAINED CPP results in higher levels of myocardial ATP and survival

3 Phase Model

Understanding Coronary Perfusion Pressure

Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure

ROSC Associated with CPP

Overview of ECC 2010 Changes

Hands Only CPR

Single biggest change ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons

Hands Only CPR

Of note some healthcare providers and laypersons indicate that reluctance to perform mouth-to-mouth ventilation for victims of cardiac arrest is a theoretical and potential barrier to performing bystander CPR

When actual bystanders were interviewed however such reluctance was not expressed panic was cited as the major obstacle to laypersons performance of bystander CPR

The simpler Hands-Only technique may help overcome panic and hesitation to act in both regards

KEY POINT

HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR in LAY RESCUERS

This presumes that traditional CPR with ventilation will eventually be performed

The exact interval in which hands only CPR is more beneficial over traditional CPR is not known

CAB

Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

Confusion in Agonal Respirations vs Good Respirations

The rescuer should treat the victim who has occasional gasps as if he or she is not breathing (Class ILOE C)

The HCP will combine their assessment for respirations with assessment for responsiveness

The Layperson will assume that if the patient is completely unresponsive they have ineffective respirations

A simultaneous choreographed approach Much more emphasis on the team approach and a realistic

recognition of what and how PARAMEDICS do their job

Recognition that resuscitation is not a ldquolinierrdquo process (Step A THEN Step B etc) but a simultaneous series of actions

ldquohellipin a highly specialized environment such as a critical care unit of a hospital many of the individual components of CPR (compression-ventilation-defibrillation) may be managed simultaneously This approach requires choreography among many highly-trained rescuers who work as an integrated team

In the pre-hospital setting the order of the CPR components performed by the healthcare provider may switch between a sequenced and choreographed model depending on the proficiency of the provider and the availability of resourcesrdquo

- Circulation 2010122[suppl 3]S676 ndashS684

ldquo It is reasonable for healthcare providers to tailor the sequence of rescue actions to the most likely cause of arrestrdquo

THIS MEANS NO MORE COOK-BOOK MEDICINE

New CPR Guidelines

Traditional Healthcare Version

2005 to 2010 changes

Component of CPR

2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

PULSE CHECK HCP Only HCP only Checking for ldquoDEFNITE pulserdquo

SOME THINGS REMAIN IMPORTANTSOME THINGS REMAIN IMPORTANT

RATERATE

DEPTHDEPTH

RELEASERELEASE

UNINTERRUPTEDUNINTERRUPTED

DECREASED DECREASED VENTILATIONVENTILATION

5 KEY5 KEY ASPECTSASPECTS

OFOF GOODGOOD CPRCPR

Compression Rate (at least 100 Minute)

Rate per minute is NOT a function of ldquospeedrdquo of compressions only but a function of both speed ands minimizing no-flow periods (discussed later) for a total compressionsminute

Compressions rates as high as 130 resulted in favorable outcomes

Compression rates lt87minute saw rapid drop off in ROSC

NEW RECOMMENDATION At LEAST 100minute

Better too fast than too slow

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

76

75

58

42

Compression Rate

Target = ~100min with complete release Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH (At least 2 inches)

Previous studies show that only about 27 of compressions were deep enough (Wik 2005)

0 (none) were too deep NEW GIUDELINES The adult sternum

should be depressed at least 2 inches (5 cm) (Class IIa LOE B) with chest compression and chest recoilrelaxation times approximately equal (Class IIb LOE C)

Compression DEPTH

Target = 38-51 mm with complete release Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Complete RELEASERECOIL (Full)

Complete Recoil essential to reduce intrathoracic pressure between compressions

Reducing recoil improves hemodynamics in arrest and improves Coronary Perfusion Pressure (CPP)

Incomplete chest wall recoil can be reduced during CPR by using electronic recording devices that provide real-time feedback

Niles D Nysaether J Sutton R Nishisaki A Abella BS Arbogast K Maltese MR Berg RA Helfaer M Nadkarni V Leaning is common during in-hospital

pediatric CPR and decreased with automated corrective feedback Resuscitation 200980553ndash557

Intra-thoracic Pressure and CPR

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and Recoil

Abella et al 2005 Circulation

INTURRUPTIONS

Pausing for procedures intubation IV pulse check etc)

Pausing for rhythm analysis Pausing after shock to await post-

shock rhythm Pausing to charge clear and shock Unaware of importance of CPR in

ldquobig picturerdquo

No-Flow Ratio (Interruption of CPR)

Target = less than 20 Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

KEY POINT

ldquohellipHigh-quality CPR is important not only at the onset but throughout the course of resuscitation Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPRrdquo

AHA 2010 Guidelines

DECREASING VENTILATION

CPR with Advanced Airway 8 ndash 10 breathsminute

Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

ECC and DEATH

New TERMS DNR

DNAR Do not attempt Resuscitation AND Allow Natural Death

Principle of Futility Defined as lt1 chance of success or

positive outcome

Withholding Resuscitation

Mild changes in verbage Situations where attempts to perform CPR

would place the rescuer at risk of serious injury or mortal peril

Obvious clinical signs of irreversible death (eg rigor-mortis dependent lividity decapitation transection or decomposition)

A valid signed and dated advance directive indicating that resuscitation is not desired or a valid signed and dated DNAR order

Termination of Resuscitation- BLS when ALS is not available or delayed

All 3 of the following criteria must be present before moving to the ambulance for transport to consider terminating BLS resuscitative attempts for adult victims of out-of-hospital cardiac arrest (1)Arrest was not witnessed by EMS provider or first responder (2) No return of spontaneous circulation (ROSC) after 3 full rounds of CPR and automated external defibrillator (AED) analysis (3) and no AED shocks were deliveredThis is to be used in conjunction with consultation with real time on line medical control

(Class IIb LOE A)

Termination of Resuscitation- ALS

All 3 of the following criteria must be present before moving to the ambulance for transport to consider terminating BLS and ALS resuscitative attempts for adult victims of out-of-hospital cardiac arrest (1)Arrest was not witnessed by EMS provider or first responder (2) No return of spontaneous circulation (ROSC) after ldquofull ALS carerdquo (defined as 20 minutes of ALS and an advanced airway (3) and no AED shocks were delivered prior to ALS arrival

(Class IIa LOE B)

Why Terminate

Termination of Resuscitative Efforts and Transport Implications

Field termination reduces unnecessary transport to the hospital by 60 with the BLS rule and 40 with the ALS rule reducing associated road hazards that put the provider patient and public at risk

In addition field termination reduces inadvertent paramedic exposure to potential biohazards and the higher cost of ED pronouncement

More importantly the quality of CPR is compromised during transport and survival is linked to optimizing scene care rather than rushing to hospital

Termination of Resuscitation in Pediatrics

No predictors of neonatal or pediatric (infant or child) out-of hospital resuscitation success or failure have been established

No validated clinical decision rules have been derived and evaluated Further research in this area is needed

In the absence of clinical decision rules for the neonatal or pediatric OHCA victim the responsible prehospital provider should follow BLS pediatric and advanced cardiovascular life support protocols and consult with real-time medical direction or transport the victim to the most appropriate facility per local directives

Other Ethical Questions we did not discuss that are in the AHA documents

In hospital cardiac arrest ethical decisions

Withholding and withdrawing care in the newborn and neonate especially pre-term and low birthweight

Organ and Tissue Donation after resuscitation

Ethics of resuscitation research Ethics of training on the newly dead

CPR WIN (Whats Important Now)

90 of all changes to 2010 ECC are right in the BLS segment

Builds on and further enhances the changes and research discussed in the 2005 guidelines

COMPRESSIONS are the single most emphasized segment of resuscitation

GOOD and SUSTAINED Coronary Perfusion Pressure is the GOAL

Understanding CPP

Coronary Perfusion Pressure (CPP) is essential to ROSC

When arrest is present for more than a few minutes the myocardium is depleted of oxygen and metabolic substrates

A brief period of (good and sustained) chest compressions can deliver oxygen and energy substrates (ie ATP) increasing the likelihood that a shock may terminate VF (defibrillation) and a perfusing rhythm will return (ie ROSC)

Without this a shock may result in ldquoSECONDARY ASYSTOLErdquo

GOOD and SUSTAINED CPP results in higher levels of myocardial ATP and survival

3 Phase Model

Understanding Coronary Perfusion Pressure

Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure

ROSC Associated with CPP

Overview of ECC 2010 Changes

Hands Only CPR

Single biggest change ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons

Hands Only CPR

Of note some healthcare providers and laypersons indicate that reluctance to perform mouth-to-mouth ventilation for victims of cardiac arrest is a theoretical and potential barrier to performing bystander CPR

When actual bystanders were interviewed however such reluctance was not expressed panic was cited as the major obstacle to laypersons performance of bystander CPR

The simpler Hands-Only technique may help overcome panic and hesitation to act in both regards

KEY POINT

HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR in LAY RESCUERS

This presumes that traditional CPR with ventilation will eventually be performed

The exact interval in which hands only CPR is more beneficial over traditional CPR is not known

CAB

Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

Confusion in Agonal Respirations vs Good Respirations

The rescuer should treat the victim who has occasional gasps as if he or she is not breathing (Class ILOE C)

The HCP will combine their assessment for respirations with assessment for responsiveness

The Layperson will assume that if the patient is completely unresponsive they have ineffective respirations

A simultaneous choreographed approach Much more emphasis on the team approach and a realistic

recognition of what and how PARAMEDICS do their job

Recognition that resuscitation is not a ldquolinierrdquo process (Step A THEN Step B etc) but a simultaneous series of actions

ldquohellipin a highly specialized environment such as a critical care unit of a hospital many of the individual components of CPR (compression-ventilation-defibrillation) may be managed simultaneously This approach requires choreography among many highly-trained rescuers who work as an integrated team

In the pre-hospital setting the order of the CPR components performed by the healthcare provider may switch between a sequenced and choreographed model depending on the proficiency of the provider and the availability of resourcesrdquo

- Circulation 2010122[suppl 3]S676 ndashS684

ldquo It is reasonable for healthcare providers to tailor the sequence of rescue actions to the most likely cause of arrestrdquo

THIS MEANS NO MORE COOK-BOOK MEDICINE

New CPR Guidelines

Traditional Healthcare Version

2005 to 2010 changes

Component of CPR

2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

PULSE CHECK HCP Only HCP only Checking for ldquoDEFNITE pulserdquo

SOME THINGS REMAIN IMPORTANTSOME THINGS REMAIN IMPORTANT

RATERATE

DEPTHDEPTH

RELEASERELEASE

UNINTERRUPTEDUNINTERRUPTED

DECREASED DECREASED VENTILATIONVENTILATION

5 KEY5 KEY ASPECTSASPECTS

OFOF GOODGOOD CPRCPR

Compression Rate (at least 100 Minute)

Rate per minute is NOT a function of ldquospeedrdquo of compressions only but a function of both speed ands minimizing no-flow periods (discussed later) for a total compressionsminute

Compressions rates as high as 130 resulted in favorable outcomes

Compression rates lt87minute saw rapid drop off in ROSC

NEW RECOMMENDATION At LEAST 100minute

Better too fast than too slow

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

76

75

58

42

Compression Rate

Target = ~100min with complete release Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH (At least 2 inches)

Previous studies show that only about 27 of compressions were deep enough (Wik 2005)

0 (none) were too deep NEW GIUDELINES The adult sternum

should be depressed at least 2 inches (5 cm) (Class IIa LOE B) with chest compression and chest recoilrelaxation times approximately equal (Class IIb LOE C)

Compression DEPTH

Target = 38-51 mm with complete release Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Complete RELEASERECOIL (Full)

Complete Recoil essential to reduce intrathoracic pressure between compressions

Reducing recoil improves hemodynamics in arrest and improves Coronary Perfusion Pressure (CPP)

Incomplete chest wall recoil can be reduced during CPR by using electronic recording devices that provide real-time feedback

Niles D Nysaether J Sutton R Nishisaki A Abella BS Arbogast K Maltese MR Berg RA Helfaer M Nadkarni V Leaning is common during in-hospital

pediatric CPR and decreased with automated corrective feedback Resuscitation 200980553ndash557

Intra-thoracic Pressure and CPR

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and Recoil

Abella et al 2005 Circulation

INTURRUPTIONS

Pausing for procedures intubation IV pulse check etc)

Pausing for rhythm analysis Pausing after shock to await post-

shock rhythm Pausing to charge clear and shock Unaware of importance of CPR in

ldquobig picturerdquo

No-Flow Ratio (Interruption of CPR)

Target = less than 20 Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

KEY POINT

ldquohellipHigh-quality CPR is important not only at the onset but throughout the course of resuscitation Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPRrdquo

AHA 2010 Guidelines

DECREASING VENTILATION

CPR with Advanced Airway 8 ndash 10 breathsminute

Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Withholding Resuscitation

Mild changes in verbage Situations where attempts to perform CPR

would place the rescuer at risk of serious injury or mortal peril

Obvious clinical signs of irreversible death (eg rigor-mortis dependent lividity decapitation transection or decomposition)

A valid signed and dated advance directive indicating that resuscitation is not desired or a valid signed and dated DNAR order

Termination of Resuscitation- BLS when ALS is not available or delayed

All 3 of the following criteria must be present before moving to the ambulance for transport to consider terminating BLS resuscitative attempts for adult victims of out-of-hospital cardiac arrest (1)Arrest was not witnessed by EMS provider or first responder (2) No return of spontaneous circulation (ROSC) after 3 full rounds of CPR and automated external defibrillator (AED) analysis (3) and no AED shocks were deliveredThis is to be used in conjunction with consultation with real time on line medical control

(Class IIb LOE A)

Termination of Resuscitation- ALS

All 3 of the following criteria must be present before moving to the ambulance for transport to consider terminating BLS and ALS resuscitative attempts for adult victims of out-of-hospital cardiac arrest (1)Arrest was not witnessed by EMS provider or first responder (2) No return of spontaneous circulation (ROSC) after ldquofull ALS carerdquo (defined as 20 minutes of ALS and an advanced airway (3) and no AED shocks were delivered prior to ALS arrival

(Class IIa LOE B)

Why Terminate

Termination of Resuscitative Efforts and Transport Implications

Field termination reduces unnecessary transport to the hospital by 60 with the BLS rule and 40 with the ALS rule reducing associated road hazards that put the provider patient and public at risk

In addition field termination reduces inadvertent paramedic exposure to potential biohazards and the higher cost of ED pronouncement

More importantly the quality of CPR is compromised during transport and survival is linked to optimizing scene care rather than rushing to hospital

Termination of Resuscitation in Pediatrics

No predictors of neonatal or pediatric (infant or child) out-of hospital resuscitation success or failure have been established

No validated clinical decision rules have been derived and evaluated Further research in this area is needed

In the absence of clinical decision rules for the neonatal or pediatric OHCA victim the responsible prehospital provider should follow BLS pediatric and advanced cardiovascular life support protocols and consult with real-time medical direction or transport the victim to the most appropriate facility per local directives

Other Ethical Questions we did not discuss that are in the AHA documents

In hospital cardiac arrest ethical decisions

Withholding and withdrawing care in the newborn and neonate especially pre-term and low birthweight

Organ and Tissue Donation after resuscitation

Ethics of resuscitation research Ethics of training on the newly dead

CPR WIN (Whats Important Now)

90 of all changes to 2010 ECC are right in the BLS segment

Builds on and further enhances the changes and research discussed in the 2005 guidelines

COMPRESSIONS are the single most emphasized segment of resuscitation

GOOD and SUSTAINED Coronary Perfusion Pressure is the GOAL

Understanding CPP

Coronary Perfusion Pressure (CPP) is essential to ROSC

When arrest is present for more than a few minutes the myocardium is depleted of oxygen and metabolic substrates

A brief period of (good and sustained) chest compressions can deliver oxygen and energy substrates (ie ATP) increasing the likelihood that a shock may terminate VF (defibrillation) and a perfusing rhythm will return (ie ROSC)

Without this a shock may result in ldquoSECONDARY ASYSTOLErdquo

GOOD and SUSTAINED CPP results in higher levels of myocardial ATP and survival

3 Phase Model

Understanding Coronary Perfusion Pressure

Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure

ROSC Associated with CPP

Overview of ECC 2010 Changes

Hands Only CPR

Single biggest change ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons

Hands Only CPR

Of note some healthcare providers and laypersons indicate that reluctance to perform mouth-to-mouth ventilation for victims of cardiac arrest is a theoretical and potential barrier to performing bystander CPR

When actual bystanders were interviewed however such reluctance was not expressed panic was cited as the major obstacle to laypersons performance of bystander CPR

The simpler Hands-Only technique may help overcome panic and hesitation to act in both regards

KEY POINT

HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR in LAY RESCUERS

This presumes that traditional CPR with ventilation will eventually be performed

The exact interval in which hands only CPR is more beneficial over traditional CPR is not known

CAB

Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

Confusion in Agonal Respirations vs Good Respirations

The rescuer should treat the victim who has occasional gasps as if he or she is not breathing (Class ILOE C)

The HCP will combine their assessment for respirations with assessment for responsiveness

The Layperson will assume that if the patient is completely unresponsive they have ineffective respirations

A simultaneous choreographed approach Much more emphasis on the team approach and a realistic

recognition of what and how PARAMEDICS do their job

Recognition that resuscitation is not a ldquolinierrdquo process (Step A THEN Step B etc) but a simultaneous series of actions

ldquohellipin a highly specialized environment such as a critical care unit of a hospital many of the individual components of CPR (compression-ventilation-defibrillation) may be managed simultaneously This approach requires choreography among many highly-trained rescuers who work as an integrated team

In the pre-hospital setting the order of the CPR components performed by the healthcare provider may switch between a sequenced and choreographed model depending on the proficiency of the provider and the availability of resourcesrdquo

- Circulation 2010122[suppl 3]S676 ndashS684

ldquo It is reasonable for healthcare providers to tailor the sequence of rescue actions to the most likely cause of arrestrdquo

THIS MEANS NO MORE COOK-BOOK MEDICINE

New CPR Guidelines

Traditional Healthcare Version

2005 to 2010 changes

Component of CPR

2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

PULSE CHECK HCP Only HCP only Checking for ldquoDEFNITE pulserdquo

SOME THINGS REMAIN IMPORTANTSOME THINGS REMAIN IMPORTANT

RATERATE

DEPTHDEPTH

RELEASERELEASE

UNINTERRUPTEDUNINTERRUPTED

DECREASED DECREASED VENTILATIONVENTILATION

5 KEY5 KEY ASPECTSASPECTS

OFOF GOODGOOD CPRCPR

Compression Rate (at least 100 Minute)

Rate per minute is NOT a function of ldquospeedrdquo of compressions only but a function of both speed ands minimizing no-flow periods (discussed later) for a total compressionsminute

Compressions rates as high as 130 resulted in favorable outcomes

Compression rates lt87minute saw rapid drop off in ROSC

NEW RECOMMENDATION At LEAST 100minute

Better too fast than too slow

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

76

75

58

42

Compression Rate

Target = ~100min with complete release Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH (At least 2 inches)

Previous studies show that only about 27 of compressions were deep enough (Wik 2005)

0 (none) were too deep NEW GIUDELINES The adult sternum

should be depressed at least 2 inches (5 cm) (Class IIa LOE B) with chest compression and chest recoilrelaxation times approximately equal (Class IIb LOE C)

Compression DEPTH

Target = 38-51 mm with complete release Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Complete RELEASERECOIL (Full)

Complete Recoil essential to reduce intrathoracic pressure between compressions

Reducing recoil improves hemodynamics in arrest and improves Coronary Perfusion Pressure (CPP)

Incomplete chest wall recoil can be reduced during CPR by using electronic recording devices that provide real-time feedback

Niles D Nysaether J Sutton R Nishisaki A Abella BS Arbogast K Maltese MR Berg RA Helfaer M Nadkarni V Leaning is common during in-hospital

pediatric CPR and decreased with automated corrective feedback Resuscitation 200980553ndash557

Intra-thoracic Pressure and CPR

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and Recoil

Abella et al 2005 Circulation

INTURRUPTIONS

Pausing for procedures intubation IV pulse check etc)

Pausing for rhythm analysis Pausing after shock to await post-

shock rhythm Pausing to charge clear and shock Unaware of importance of CPR in

ldquobig picturerdquo

No-Flow Ratio (Interruption of CPR)

Target = less than 20 Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

KEY POINT

ldquohellipHigh-quality CPR is important not only at the onset but throughout the course of resuscitation Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPRrdquo

AHA 2010 Guidelines

DECREASING VENTILATION

CPR with Advanced Airway 8 ndash 10 breathsminute

Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Termination of Resuscitation- BLS when ALS is not available or delayed

All 3 of the following criteria must be present before moving to the ambulance for transport to consider terminating BLS resuscitative attempts for adult victims of out-of-hospital cardiac arrest (1)Arrest was not witnessed by EMS provider or first responder (2) No return of spontaneous circulation (ROSC) after 3 full rounds of CPR and automated external defibrillator (AED) analysis (3) and no AED shocks were deliveredThis is to be used in conjunction with consultation with real time on line medical control

(Class IIb LOE A)

Termination of Resuscitation- ALS

All 3 of the following criteria must be present before moving to the ambulance for transport to consider terminating BLS and ALS resuscitative attempts for adult victims of out-of-hospital cardiac arrest (1)Arrest was not witnessed by EMS provider or first responder (2) No return of spontaneous circulation (ROSC) after ldquofull ALS carerdquo (defined as 20 minutes of ALS and an advanced airway (3) and no AED shocks were delivered prior to ALS arrival

(Class IIa LOE B)

Why Terminate

Termination of Resuscitative Efforts and Transport Implications

Field termination reduces unnecessary transport to the hospital by 60 with the BLS rule and 40 with the ALS rule reducing associated road hazards that put the provider patient and public at risk

In addition field termination reduces inadvertent paramedic exposure to potential biohazards and the higher cost of ED pronouncement

More importantly the quality of CPR is compromised during transport and survival is linked to optimizing scene care rather than rushing to hospital

Termination of Resuscitation in Pediatrics

No predictors of neonatal or pediatric (infant or child) out-of hospital resuscitation success or failure have been established

No validated clinical decision rules have been derived and evaluated Further research in this area is needed

In the absence of clinical decision rules for the neonatal or pediatric OHCA victim the responsible prehospital provider should follow BLS pediatric and advanced cardiovascular life support protocols and consult with real-time medical direction or transport the victim to the most appropriate facility per local directives

Other Ethical Questions we did not discuss that are in the AHA documents

In hospital cardiac arrest ethical decisions

Withholding and withdrawing care in the newborn and neonate especially pre-term and low birthweight

Organ and Tissue Donation after resuscitation

Ethics of resuscitation research Ethics of training on the newly dead

CPR WIN (Whats Important Now)

90 of all changes to 2010 ECC are right in the BLS segment

Builds on and further enhances the changes and research discussed in the 2005 guidelines

COMPRESSIONS are the single most emphasized segment of resuscitation

GOOD and SUSTAINED Coronary Perfusion Pressure is the GOAL

Understanding CPP

Coronary Perfusion Pressure (CPP) is essential to ROSC

When arrest is present for more than a few minutes the myocardium is depleted of oxygen and metabolic substrates

A brief period of (good and sustained) chest compressions can deliver oxygen and energy substrates (ie ATP) increasing the likelihood that a shock may terminate VF (defibrillation) and a perfusing rhythm will return (ie ROSC)

Without this a shock may result in ldquoSECONDARY ASYSTOLErdquo

GOOD and SUSTAINED CPP results in higher levels of myocardial ATP and survival

3 Phase Model

Understanding Coronary Perfusion Pressure

Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure

ROSC Associated with CPP

Overview of ECC 2010 Changes

Hands Only CPR

Single biggest change ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons

Hands Only CPR

Of note some healthcare providers and laypersons indicate that reluctance to perform mouth-to-mouth ventilation for victims of cardiac arrest is a theoretical and potential barrier to performing bystander CPR

When actual bystanders were interviewed however such reluctance was not expressed panic was cited as the major obstacle to laypersons performance of bystander CPR

The simpler Hands-Only technique may help overcome panic and hesitation to act in both regards

KEY POINT

HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR in LAY RESCUERS

This presumes that traditional CPR with ventilation will eventually be performed

The exact interval in which hands only CPR is more beneficial over traditional CPR is not known

CAB

Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

Confusion in Agonal Respirations vs Good Respirations

The rescuer should treat the victim who has occasional gasps as if he or she is not breathing (Class ILOE C)

The HCP will combine their assessment for respirations with assessment for responsiveness

The Layperson will assume that if the patient is completely unresponsive they have ineffective respirations

A simultaneous choreographed approach Much more emphasis on the team approach and a realistic

recognition of what and how PARAMEDICS do their job

Recognition that resuscitation is not a ldquolinierrdquo process (Step A THEN Step B etc) but a simultaneous series of actions

ldquohellipin a highly specialized environment such as a critical care unit of a hospital many of the individual components of CPR (compression-ventilation-defibrillation) may be managed simultaneously This approach requires choreography among many highly-trained rescuers who work as an integrated team

In the pre-hospital setting the order of the CPR components performed by the healthcare provider may switch between a sequenced and choreographed model depending on the proficiency of the provider and the availability of resourcesrdquo

- Circulation 2010122[suppl 3]S676 ndashS684

ldquo It is reasonable for healthcare providers to tailor the sequence of rescue actions to the most likely cause of arrestrdquo

THIS MEANS NO MORE COOK-BOOK MEDICINE

New CPR Guidelines

Traditional Healthcare Version

2005 to 2010 changes

Component of CPR

2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

PULSE CHECK HCP Only HCP only Checking for ldquoDEFNITE pulserdquo

SOME THINGS REMAIN IMPORTANTSOME THINGS REMAIN IMPORTANT

RATERATE

DEPTHDEPTH

RELEASERELEASE

UNINTERRUPTEDUNINTERRUPTED

DECREASED DECREASED VENTILATIONVENTILATION

5 KEY5 KEY ASPECTSASPECTS

OFOF GOODGOOD CPRCPR

Compression Rate (at least 100 Minute)

Rate per minute is NOT a function of ldquospeedrdquo of compressions only but a function of both speed ands minimizing no-flow periods (discussed later) for a total compressionsminute

Compressions rates as high as 130 resulted in favorable outcomes

Compression rates lt87minute saw rapid drop off in ROSC

NEW RECOMMENDATION At LEAST 100minute

Better too fast than too slow

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

76

75

58

42

Compression Rate

Target = ~100min with complete release Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH (At least 2 inches)

Previous studies show that only about 27 of compressions were deep enough (Wik 2005)

0 (none) were too deep NEW GIUDELINES The adult sternum

should be depressed at least 2 inches (5 cm) (Class IIa LOE B) with chest compression and chest recoilrelaxation times approximately equal (Class IIb LOE C)

Compression DEPTH

Target = 38-51 mm with complete release Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Complete RELEASERECOIL (Full)

Complete Recoil essential to reduce intrathoracic pressure between compressions

Reducing recoil improves hemodynamics in arrest and improves Coronary Perfusion Pressure (CPP)

Incomplete chest wall recoil can be reduced during CPR by using electronic recording devices that provide real-time feedback

Niles D Nysaether J Sutton R Nishisaki A Abella BS Arbogast K Maltese MR Berg RA Helfaer M Nadkarni V Leaning is common during in-hospital

pediatric CPR and decreased with automated corrective feedback Resuscitation 200980553ndash557

Intra-thoracic Pressure and CPR

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and Recoil

Abella et al 2005 Circulation

INTURRUPTIONS

Pausing for procedures intubation IV pulse check etc)

Pausing for rhythm analysis Pausing after shock to await post-

shock rhythm Pausing to charge clear and shock Unaware of importance of CPR in

ldquobig picturerdquo

No-Flow Ratio (Interruption of CPR)

Target = less than 20 Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

KEY POINT

ldquohellipHigh-quality CPR is important not only at the onset but throughout the course of resuscitation Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPRrdquo

AHA 2010 Guidelines

DECREASING VENTILATION

CPR with Advanced Airway 8 ndash 10 breathsminute

Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Termination of Resuscitation- ALS

All 3 of the following criteria must be present before moving to the ambulance for transport to consider terminating BLS and ALS resuscitative attempts for adult victims of out-of-hospital cardiac arrest (1)Arrest was not witnessed by EMS provider or first responder (2) No return of spontaneous circulation (ROSC) after ldquofull ALS carerdquo (defined as 20 minutes of ALS and an advanced airway (3) and no AED shocks were delivered prior to ALS arrival

(Class IIa LOE B)

Why Terminate

Termination of Resuscitative Efforts and Transport Implications

Field termination reduces unnecessary transport to the hospital by 60 with the BLS rule and 40 with the ALS rule reducing associated road hazards that put the provider patient and public at risk

In addition field termination reduces inadvertent paramedic exposure to potential biohazards and the higher cost of ED pronouncement

More importantly the quality of CPR is compromised during transport and survival is linked to optimizing scene care rather than rushing to hospital

Termination of Resuscitation in Pediatrics

No predictors of neonatal or pediatric (infant or child) out-of hospital resuscitation success or failure have been established

No validated clinical decision rules have been derived and evaluated Further research in this area is needed

In the absence of clinical decision rules for the neonatal or pediatric OHCA victim the responsible prehospital provider should follow BLS pediatric and advanced cardiovascular life support protocols and consult with real-time medical direction or transport the victim to the most appropriate facility per local directives

Other Ethical Questions we did not discuss that are in the AHA documents

In hospital cardiac arrest ethical decisions

Withholding and withdrawing care in the newborn and neonate especially pre-term and low birthweight

Organ and Tissue Donation after resuscitation

Ethics of resuscitation research Ethics of training on the newly dead

CPR WIN (Whats Important Now)

90 of all changes to 2010 ECC are right in the BLS segment

Builds on and further enhances the changes and research discussed in the 2005 guidelines

COMPRESSIONS are the single most emphasized segment of resuscitation

GOOD and SUSTAINED Coronary Perfusion Pressure is the GOAL

Understanding CPP

Coronary Perfusion Pressure (CPP) is essential to ROSC

When arrest is present for more than a few minutes the myocardium is depleted of oxygen and metabolic substrates

A brief period of (good and sustained) chest compressions can deliver oxygen and energy substrates (ie ATP) increasing the likelihood that a shock may terminate VF (defibrillation) and a perfusing rhythm will return (ie ROSC)

Without this a shock may result in ldquoSECONDARY ASYSTOLErdquo

GOOD and SUSTAINED CPP results in higher levels of myocardial ATP and survival

3 Phase Model

Understanding Coronary Perfusion Pressure

Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure

ROSC Associated with CPP

Overview of ECC 2010 Changes

Hands Only CPR

Single biggest change ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons

Hands Only CPR

Of note some healthcare providers and laypersons indicate that reluctance to perform mouth-to-mouth ventilation for victims of cardiac arrest is a theoretical and potential barrier to performing bystander CPR

When actual bystanders were interviewed however such reluctance was not expressed panic was cited as the major obstacle to laypersons performance of bystander CPR

The simpler Hands-Only technique may help overcome panic and hesitation to act in both regards

KEY POINT

HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR in LAY RESCUERS

This presumes that traditional CPR with ventilation will eventually be performed

The exact interval in which hands only CPR is more beneficial over traditional CPR is not known

CAB

Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

Confusion in Agonal Respirations vs Good Respirations

The rescuer should treat the victim who has occasional gasps as if he or she is not breathing (Class ILOE C)

The HCP will combine their assessment for respirations with assessment for responsiveness

The Layperson will assume that if the patient is completely unresponsive they have ineffective respirations

A simultaneous choreographed approach Much more emphasis on the team approach and a realistic

recognition of what and how PARAMEDICS do their job

Recognition that resuscitation is not a ldquolinierrdquo process (Step A THEN Step B etc) but a simultaneous series of actions

ldquohellipin a highly specialized environment such as a critical care unit of a hospital many of the individual components of CPR (compression-ventilation-defibrillation) may be managed simultaneously This approach requires choreography among many highly-trained rescuers who work as an integrated team

In the pre-hospital setting the order of the CPR components performed by the healthcare provider may switch between a sequenced and choreographed model depending on the proficiency of the provider and the availability of resourcesrdquo

- Circulation 2010122[suppl 3]S676 ndashS684

ldquo It is reasonable for healthcare providers to tailor the sequence of rescue actions to the most likely cause of arrestrdquo

THIS MEANS NO MORE COOK-BOOK MEDICINE

New CPR Guidelines

Traditional Healthcare Version

2005 to 2010 changes

Component of CPR

2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

PULSE CHECK HCP Only HCP only Checking for ldquoDEFNITE pulserdquo

SOME THINGS REMAIN IMPORTANTSOME THINGS REMAIN IMPORTANT

RATERATE

DEPTHDEPTH

RELEASERELEASE

UNINTERRUPTEDUNINTERRUPTED

DECREASED DECREASED VENTILATIONVENTILATION

5 KEY5 KEY ASPECTSASPECTS

OFOF GOODGOOD CPRCPR

Compression Rate (at least 100 Minute)

Rate per minute is NOT a function of ldquospeedrdquo of compressions only but a function of both speed ands minimizing no-flow periods (discussed later) for a total compressionsminute

Compressions rates as high as 130 resulted in favorable outcomes

Compression rates lt87minute saw rapid drop off in ROSC

NEW RECOMMENDATION At LEAST 100minute

Better too fast than too slow

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

76

75

58

42

Compression Rate

Target = ~100min with complete release Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH (At least 2 inches)

Previous studies show that only about 27 of compressions were deep enough (Wik 2005)

0 (none) were too deep NEW GIUDELINES The adult sternum

should be depressed at least 2 inches (5 cm) (Class IIa LOE B) with chest compression and chest recoilrelaxation times approximately equal (Class IIb LOE C)

Compression DEPTH

Target = 38-51 mm with complete release Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Complete RELEASERECOIL (Full)

Complete Recoil essential to reduce intrathoracic pressure between compressions

Reducing recoil improves hemodynamics in arrest and improves Coronary Perfusion Pressure (CPP)

Incomplete chest wall recoil can be reduced during CPR by using electronic recording devices that provide real-time feedback

Niles D Nysaether J Sutton R Nishisaki A Abella BS Arbogast K Maltese MR Berg RA Helfaer M Nadkarni V Leaning is common during in-hospital

pediatric CPR and decreased with automated corrective feedback Resuscitation 200980553ndash557

Intra-thoracic Pressure and CPR

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and Recoil

Abella et al 2005 Circulation

INTURRUPTIONS

Pausing for procedures intubation IV pulse check etc)

Pausing for rhythm analysis Pausing after shock to await post-

shock rhythm Pausing to charge clear and shock Unaware of importance of CPR in

ldquobig picturerdquo

No-Flow Ratio (Interruption of CPR)

Target = less than 20 Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

KEY POINT

ldquohellipHigh-quality CPR is important not only at the onset but throughout the course of resuscitation Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPRrdquo

AHA 2010 Guidelines

DECREASING VENTILATION

CPR with Advanced Airway 8 ndash 10 breathsminute

Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Why Terminate

Termination of Resuscitative Efforts and Transport Implications

Field termination reduces unnecessary transport to the hospital by 60 with the BLS rule and 40 with the ALS rule reducing associated road hazards that put the provider patient and public at risk

In addition field termination reduces inadvertent paramedic exposure to potential biohazards and the higher cost of ED pronouncement

More importantly the quality of CPR is compromised during transport and survival is linked to optimizing scene care rather than rushing to hospital

Termination of Resuscitation in Pediatrics

No predictors of neonatal or pediatric (infant or child) out-of hospital resuscitation success or failure have been established

No validated clinical decision rules have been derived and evaluated Further research in this area is needed

In the absence of clinical decision rules for the neonatal or pediatric OHCA victim the responsible prehospital provider should follow BLS pediatric and advanced cardiovascular life support protocols and consult with real-time medical direction or transport the victim to the most appropriate facility per local directives

Other Ethical Questions we did not discuss that are in the AHA documents

In hospital cardiac arrest ethical decisions

Withholding and withdrawing care in the newborn and neonate especially pre-term and low birthweight

Organ and Tissue Donation after resuscitation

Ethics of resuscitation research Ethics of training on the newly dead

CPR WIN (Whats Important Now)

90 of all changes to 2010 ECC are right in the BLS segment

Builds on and further enhances the changes and research discussed in the 2005 guidelines

COMPRESSIONS are the single most emphasized segment of resuscitation

GOOD and SUSTAINED Coronary Perfusion Pressure is the GOAL

Understanding CPP

Coronary Perfusion Pressure (CPP) is essential to ROSC

When arrest is present for more than a few minutes the myocardium is depleted of oxygen and metabolic substrates

A brief period of (good and sustained) chest compressions can deliver oxygen and energy substrates (ie ATP) increasing the likelihood that a shock may terminate VF (defibrillation) and a perfusing rhythm will return (ie ROSC)

Without this a shock may result in ldquoSECONDARY ASYSTOLErdquo

GOOD and SUSTAINED CPP results in higher levels of myocardial ATP and survival

3 Phase Model

Understanding Coronary Perfusion Pressure

Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure

ROSC Associated with CPP

Overview of ECC 2010 Changes

Hands Only CPR

Single biggest change ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons

Hands Only CPR

Of note some healthcare providers and laypersons indicate that reluctance to perform mouth-to-mouth ventilation for victims of cardiac arrest is a theoretical and potential barrier to performing bystander CPR

When actual bystanders were interviewed however such reluctance was not expressed panic was cited as the major obstacle to laypersons performance of bystander CPR

The simpler Hands-Only technique may help overcome panic and hesitation to act in both regards

KEY POINT

HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR in LAY RESCUERS

This presumes that traditional CPR with ventilation will eventually be performed

The exact interval in which hands only CPR is more beneficial over traditional CPR is not known

CAB

Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

Confusion in Agonal Respirations vs Good Respirations

The rescuer should treat the victim who has occasional gasps as if he or she is not breathing (Class ILOE C)

The HCP will combine their assessment for respirations with assessment for responsiveness

The Layperson will assume that if the patient is completely unresponsive they have ineffective respirations

A simultaneous choreographed approach Much more emphasis on the team approach and a realistic

recognition of what and how PARAMEDICS do their job

Recognition that resuscitation is not a ldquolinierrdquo process (Step A THEN Step B etc) but a simultaneous series of actions

ldquohellipin a highly specialized environment such as a critical care unit of a hospital many of the individual components of CPR (compression-ventilation-defibrillation) may be managed simultaneously This approach requires choreography among many highly-trained rescuers who work as an integrated team

In the pre-hospital setting the order of the CPR components performed by the healthcare provider may switch between a sequenced and choreographed model depending on the proficiency of the provider and the availability of resourcesrdquo

- Circulation 2010122[suppl 3]S676 ndashS684

ldquo It is reasonable for healthcare providers to tailor the sequence of rescue actions to the most likely cause of arrestrdquo

THIS MEANS NO MORE COOK-BOOK MEDICINE

New CPR Guidelines

Traditional Healthcare Version

2005 to 2010 changes

Component of CPR

2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

PULSE CHECK HCP Only HCP only Checking for ldquoDEFNITE pulserdquo

SOME THINGS REMAIN IMPORTANTSOME THINGS REMAIN IMPORTANT

RATERATE

DEPTHDEPTH

RELEASERELEASE

UNINTERRUPTEDUNINTERRUPTED

DECREASED DECREASED VENTILATIONVENTILATION

5 KEY5 KEY ASPECTSASPECTS

OFOF GOODGOOD CPRCPR

Compression Rate (at least 100 Minute)

Rate per minute is NOT a function of ldquospeedrdquo of compressions only but a function of both speed ands minimizing no-flow periods (discussed later) for a total compressionsminute

Compressions rates as high as 130 resulted in favorable outcomes

Compression rates lt87minute saw rapid drop off in ROSC

NEW RECOMMENDATION At LEAST 100minute

Better too fast than too slow

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

76

75

58

42

Compression Rate

Target = ~100min with complete release Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH (At least 2 inches)

Previous studies show that only about 27 of compressions were deep enough (Wik 2005)

0 (none) were too deep NEW GIUDELINES The adult sternum

should be depressed at least 2 inches (5 cm) (Class IIa LOE B) with chest compression and chest recoilrelaxation times approximately equal (Class IIb LOE C)

Compression DEPTH

Target = 38-51 mm with complete release Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Complete RELEASERECOIL (Full)

Complete Recoil essential to reduce intrathoracic pressure between compressions

Reducing recoil improves hemodynamics in arrest and improves Coronary Perfusion Pressure (CPP)

Incomplete chest wall recoil can be reduced during CPR by using electronic recording devices that provide real-time feedback

Niles D Nysaether J Sutton R Nishisaki A Abella BS Arbogast K Maltese MR Berg RA Helfaer M Nadkarni V Leaning is common during in-hospital

pediatric CPR and decreased with automated corrective feedback Resuscitation 200980553ndash557

Intra-thoracic Pressure and CPR

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and Recoil

Abella et al 2005 Circulation

INTURRUPTIONS

Pausing for procedures intubation IV pulse check etc)

Pausing for rhythm analysis Pausing after shock to await post-

shock rhythm Pausing to charge clear and shock Unaware of importance of CPR in

ldquobig picturerdquo

No-Flow Ratio (Interruption of CPR)

Target = less than 20 Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

KEY POINT

ldquohellipHigh-quality CPR is important not only at the onset but throughout the course of resuscitation Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPRrdquo

AHA 2010 Guidelines

DECREASING VENTILATION

CPR with Advanced Airway 8 ndash 10 breathsminute

Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Termination of Resuscitation in Pediatrics

No predictors of neonatal or pediatric (infant or child) out-of hospital resuscitation success or failure have been established

No validated clinical decision rules have been derived and evaluated Further research in this area is needed

In the absence of clinical decision rules for the neonatal or pediatric OHCA victim the responsible prehospital provider should follow BLS pediatric and advanced cardiovascular life support protocols and consult with real-time medical direction or transport the victim to the most appropriate facility per local directives

Other Ethical Questions we did not discuss that are in the AHA documents

In hospital cardiac arrest ethical decisions

Withholding and withdrawing care in the newborn and neonate especially pre-term and low birthweight

Organ and Tissue Donation after resuscitation

Ethics of resuscitation research Ethics of training on the newly dead

CPR WIN (Whats Important Now)

90 of all changes to 2010 ECC are right in the BLS segment

Builds on and further enhances the changes and research discussed in the 2005 guidelines

COMPRESSIONS are the single most emphasized segment of resuscitation

GOOD and SUSTAINED Coronary Perfusion Pressure is the GOAL

Understanding CPP

Coronary Perfusion Pressure (CPP) is essential to ROSC

When arrest is present for more than a few minutes the myocardium is depleted of oxygen and metabolic substrates

A brief period of (good and sustained) chest compressions can deliver oxygen and energy substrates (ie ATP) increasing the likelihood that a shock may terminate VF (defibrillation) and a perfusing rhythm will return (ie ROSC)

Without this a shock may result in ldquoSECONDARY ASYSTOLErdquo

GOOD and SUSTAINED CPP results in higher levels of myocardial ATP and survival

3 Phase Model

Understanding Coronary Perfusion Pressure

Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure

ROSC Associated with CPP

Overview of ECC 2010 Changes

Hands Only CPR

Single biggest change ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons

Hands Only CPR

Of note some healthcare providers and laypersons indicate that reluctance to perform mouth-to-mouth ventilation for victims of cardiac arrest is a theoretical and potential barrier to performing bystander CPR

When actual bystanders were interviewed however such reluctance was not expressed panic was cited as the major obstacle to laypersons performance of bystander CPR

The simpler Hands-Only technique may help overcome panic and hesitation to act in both regards

KEY POINT

HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR in LAY RESCUERS

This presumes that traditional CPR with ventilation will eventually be performed

The exact interval in which hands only CPR is more beneficial over traditional CPR is not known

CAB

Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

Confusion in Agonal Respirations vs Good Respirations

The rescuer should treat the victim who has occasional gasps as if he or she is not breathing (Class ILOE C)

The HCP will combine their assessment for respirations with assessment for responsiveness

The Layperson will assume that if the patient is completely unresponsive they have ineffective respirations

A simultaneous choreographed approach Much more emphasis on the team approach and a realistic

recognition of what and how PARAMEDICS do their job

Recognition that resuscitation is not a ldquolinierrdquo process (Step A THEN Step B etc) but a simultaneous series of actions

ldquohellipin a highly specialized environment such as a critical care unit of a hospital many of the individual components of CPR (compression-ventilation-defibrillation) may be managed simultaneously This approach requires choreography among many highly-trained rescuers who work as an integrated team

In the pre-hospital setting the order of the CPR components performed by the healthcare provider may switch between a sequenced and choreographed model depending on the proficiency of the provider and the availability of resourcesrdquo

- Circulation 2010122[suppl 3]S676 ndashS684

ldquo It is reasonable for healthcare providers to tailor the sequence of rescue actions to the most likely cause of arrestrdquo

THIS MEANS NO MORE COOK-BOOK MEDICINE

New CPR Guidelines

Traditional Healthcare Version

2005 to 2010 changes

Component of CPR

2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

PULSE CHECK HCP Only HCP only Checking for ldquoDEFNITE pulserdquo

SOME THINGS REMAIN IMPORTANTSOME THINGS REMAIN IMPORTANT

RATERATE

DEPTHDEPTH

RELEASERELEASE

UNINTERRUPTEDUNINTERRUPTED

DECREASED DECREASED VENTILATIONVENTILATION

5 KEY5 KEY ASPECTSASPECTS

OFOF GOODGOOD CPRCPR

Compression Rate (at least 100 Minute)

Rate per minute is NOT a function of ldquospeedrdquo of compressions only but a function of both speed ands minimizing no-flow periods (discussed later) for a total compressionsminute

Compressions rates as high as 130 resulted in favorable outcomes

Compression rates lt87minute saw rapid drop off in ROSC

NEW RECOMMENDATION At LEAST 100minute

Better too fast than too slow

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

76

75

58

42

Compression Rate

Target = ~100min with complete release Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH (At least 2 inches)

Previous studies show that only about 27 of compressions were deep enough (Wik 2005)

0 (none) were too deep NEW GIUDELINES The adult sternum

should be depressed at least 2 inches (5 cm) (Class IIa LOE B) with chest compression and chest recoilrelaxation times approximately equal (Class IIb LOE C)

Compression DEPTH

Target = 38-51 mm with complete release Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Complete RELEASERECOIL (Full)

Complete Recoil essential to reduce intrathoracic pressure between compressions

Reducing recoil improves hemodynamics in arrest and improves Coronary Perfusion Pressure (CPP)

Incomplete chest wall recoil can be reduced during CPR by using electronic recording devices that provide real-time feedback

Niles D Nysaether J Sutton R Nishisaki A Abella BS Arbogast K Maltese MR Berg RA Helfaer M Nadkarni V Leaning is common during in-hospital

pediatric CPR and decreased with automated corrective feedback Resuscitation 200980553ndash557

Intra-thoracic Pressure and CPR

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and Recoil

Abella et al 2005 Circulation

INTURRUPTIONS

Pausing for procedures intubation IV pulse check etc)

Pausing for rhythm analysis Pausing after shock to await post-

shock rhythm Pausing to charge clear and shock Unaware of importance of CPR in

ldquobig picturerdquo

No-Flow Ratio (Interruption of CPR)

Target = less than 20 Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

KEY POINT

ldquohellipHigh-quality CPR is important not only at the onset but throughout the course of resuscitation Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPRrdquo

AHA 2010 Guidelines

DECREASING VENTILATION

CPR with Advanced Airway 8 ndash 10 breathsminute

Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Other Ethical Questions we did not discuss that are in the AHA documents

In hospital cardiac arrest ethical decisions

Withholding and withdrawing care in the newborn and neonate especially pre-term and low birthweight

Organ and Tissue Donation after resuscitation

Ethics of resuscitation research Ethics of training on the newly dead

CPR WIN (Whats Important Now)

90 of all changes to 2010 ECC are right in the BLS segment

Builds on and further enhances the changes and research discussed in the 2005 guidelines

COMPRESSIONS are the single most emphasized segment of resuscitation

GOOD and SUSTAINED Coronary Perfusion Pressure is the GOAL

Understanding CPP

Coronary Perfusion Pressure (CPP) is essential to ROSC

When arrest is present for more than a few minutes the myocardium is depleted of oxygen and metabolic substrates

A brief period of (good and sustained) chest compressions can deliver oxygen and energy substrates (ie ATP) increasing the likelihood that a shock may terminate VF (defibrillation) and a perfusing rhythm will return (ie ROSC)

Without this a shock may result in ldquoSECONDARY ASYSTOLErdquo

GOOD and SUSTAINED CPP results in higher levels of myocardial ATP and survival

3 Phase Model

Understanding Coronary Perfusion Pressure

Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure

ROSC Associated with CPP

Overview of ECC 2010 Changes

Hands Only CPR

Single biggest change ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons

Hands Only CPR

Of note some healthcare providers and laypersons indicate that reluctance to perform mouth-to-mouth ventilation for victims of cardiac arrest is a theoretical and potential barrier to performing bystander CPR

When actual bystanders were interviewed however such reluctance was not expressed panic was cited as the major obstacle to laypersons performance of bystander CPR

The simpler Hands-Only technique may help overcome panic and hesitation to act in both regards

KEY POINT

HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR in LAY RESCUERS

This presumes that traditional CPR with ventilation will eventually be performed

The exact interval in which hands only CPR is more beneficial over traditional CPR is not known

CAB

Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

Confusion in Agonal Respirations vs Good Respirations

The rescuer should treat the victim who has occasional gasps as if he or she is not breathing (Class ILOE C)

The HCP will combine their assessment for respirations with assessment for responsiveness

The Layperson will assume that if the patient is completely unresponsive they have ineffective respirations

A simultaneous choreographed approach Much more emphasis on the team approach and a realistic

recognition of what and how PARAMEDICS do their job

Recognition that resuscitation is not a ldquolinierrdquo process (Step A THEN Step B etc) but a simultaneous series of actions

ldquohellipin a highly specialized environment such as a critical care unit of a hospital many of the individual components of CPR (compression-ventilation-defibrillation) may be managed simultaneously This approach requires choreography among many highly-trained rescuers who work as an integrated team

In the pre-hospital setting the order of the CPR components performed by the healthcare provider may switch between a sequenced and choreographed model depending on the proficiency of the provider and the availability of resourcesrdquo

- Circulation 2010122[suppl 3]S676 ndashS684

ldquo It is reasonable for healthcare providers to tailor the sequence of rescue actions to the most likely cause of arrestrdquo

THIS MEANS NO MORE COOK-BOOK MEDICINE

New CPR Guidelines

Traditional Healthcare Version

2005 to 2010 changes

Component of CPR

2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

PULSE CHECK HCP Only HCP only Checking for ldquoDEFNITE pulserdquo

SOME THINGS REMAIN IMPORTANTSOME THINGS REMAIN IMPORTANT

RATERATE

DEPTHDEPTH

RELEASERELEASE

UNINTERRUPTEDUNINTERRUPTED

DECREASED DECREASED VENTILATIONVENTILATION

5 KEY5 KEY ASPECTSASPECTS

OFOF GOODGOOD CPRCPR

Compression Rate (at least 100 Minute)

Rate per minute is NOT a function of ldquospeedrdquo of compressions only but a function of both speed ands minimizing no-flow periods (discussed later) for a total compressionsminute

Compressions rates as high as 130 resulted in favorable outcomes

Compression rates lt87minute saw rapid drop off in ROSC

NEW RECOMMENDATION At LEAST 100minute

Better too fast than too slow

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

76

75

58

42

Compression Rate

Target = ~100min with complete release Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH (At least 2 inches)

Previous studies show that only about 27 of compressions were deep enough (Wik 2005)

0 (none) were too deep NEW GIUDELINES The adult sternum

should be depressed at least 2 inches (5 cm) (Class IIa LOE B) with chest compression and chest recoilrelaxation times approximately equal (Class IIb LOE C)

Compression DEPTH

Target = 38-51 mm with complete release Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Complete RELEASERECOIL (Full)

Complete Recoil essential to reduce intrathoracic pressure between compressions

Reducing recoil improves hemodynamics in arrest and improves Coronary Perfusion Pressure (CPP)

Incomplete chest wall recoil can be reduced during CPR by using electronic recording devices that provide real-time feedback

Niles D Nysaether J Sutton R Nishisaki A Abella BS Arbogast K Maltese MR Berg RA Helfaer M Nadkarni V Leaning is common during in-hospital

pediatric CPR and decreased with automated corrective feedback Resuscitation 200980553ndash557

Intra-thoracic Pressure and CPR

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and Recoil

Abella et al 2005 Circulation

INTURRUPTIONS

Pausing for procedures intubation IV pulse check etc)

Pausing for rhythm analysis Pausing after shock to await post-

shock rhythm Pausing to charge clear and shock Unaware of importance of CPR in

ldquobig picturerdquo

No-Flow Ratio (Interruption of CPR)

Target = less than 20 Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

KEY POINT

ldquohellipHigh-quality CPR is important not only at the onset but throughout the course of resuscitation Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPRrdquo

AHA 2010 Guidelines

DECREASING VENTILATION

CPR with Advanced Airway 8 ndash 10 breathsminute

Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

CPR WIN (Whats Important Now)

90 of all changes to 2010 ECC are right in the BLS segment

Builds on and further enhances the changes and research discussed in the 2005 guidelines

COMPRESSIONS are the single most emphasized segment of resuscitation

GOOD and SUSTAINED Coronary Perfusion Pressure is the GOAL

Understanding CPP

Coronary Perfusion Pressure (CPP) is essential to ROSC

When arrest is present for more than a few minutes the myocardium is depleted of oxygen and metabolic substrates

A brief period of (good and sustained) chest compressions can deliver oxygen and energy substrates (ie ATP) increasing the likelihood that a shock may terminate VF (defibrillation) and a perfusing rhythm will return (ie ROSC)

Without this a shock may result in ldquoSECONDARY ASYSTOLErdquo

GOOD and SUSTAINED CPP results in higher levels of myocardial ATP and survival

3 Phase Model

Understanding Coronary Perfusion Pressure

Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure

ROSC Associated with CPP

Overview of ECC 2010 Changes

Hands Only CPR

Single biggest change ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons

Hands Only CPR

Of note some healthcare providers and laypersons indicate that reluctance to perform mouth-to-mouth ventilation for victims of cardiac arrest is a theoretical and potential barrier to performing bystander CPR

When actual bystanders were interviewed however such reluctance was not expressed panic was cited as the major obstacle to laypersons performance of bystander CPR

The simpler Hands-Only technique may help overcome panic and hesitation to act in both regards

KEY POINT

HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR in LAY RESCUERS

This presumes that traditional CPR with ventilation will eventually be performed

The exact interval in which hands only CPR is more beneficial over traditional CPR is not known

CAB

Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

Confusion in Agonal Respirations vs Good Respirations

The rescuer should treat the victim who has occasional gasps as if he or she is not breathing (Class ILOE C)

The HCP will combine their assessment for respirations with assessment for responsiveness

The Layperson will assume that if the patient is completely unresponsive they have ineffective respirations

A simultaneous choreographed approach Much more emphasis on the team approach and a realistic

recognition of what and how PARAMEDICS do their job

Recognition that resuscitation is not a ldquolinierrdquo process (Step A THEN Step B etc) but a simultaneous series of actions

ldquohellipin a highly specialized environment such as a critical care unit of a hospital many of the individual components of CPR (compression-ventilation-defibrillation) may be managed simultaneously This approach requires choreography among many highly-trained rescuers who work as an integrated team

In the pre-hospital setting the order of the CPR components performed by the healthcare provider may switch between a sequenced and choreographed model depending on the proficiency of the provider and the availability of resourcesrdquo

- Circulation 2010122[suppl 3]S676 ndashS684

ldquo It is reasonable for healthcare providers to tailor the sequence of rescue actions to the most likely cause of arrestrdquo

THIS MEANS NO MORE COOK-BOOK MEDICINE

New CPR Guidelines

Traditional Healthcare Version

2005 to 2010 changes

Component of CPR

2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

PULSE CHECK HCP Only HCP only Checking for ldquoDEFNITE pulserdquo

SOME THINGS REMAIN IMPORTANTSOME THINGS REMAIN IMPORTANT

RATERATE

DEPTHDEPTH

RELEASERELEASE

UNINTERRUPTEDUNINTERRUPTED

DECREASED DECREASED VENTILATIONVENTILATION

5 KEY5 KEY ASPECTSASPECTS

OFOF GOODGOOD CPRCPR

Compression Rate (at least 100 Minute)

Rate per minute is NOT a function of ldquospeedrdquo of compressions only but a function of both speed ands minimizing no-flow periods (discussed later) for a total compressionsminute

Compressions rates as high as 130 resulted in favorable outcomes

Compression rates lt87minute saw rapid drop off in ROSC

NEW RECOMMENDATION At LEAST 100minute

Better too fast than too slow

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

76

75

58

42

Compression Rate

Target = ~100min with complete release Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH (At least 2 inches)

Previous studies show that only about 27 of compressions were deep enough (Wik 2005)

0 (none) were too deep NEW GIUDELINES The adult sternum

should be depressed at least 2 inches (5 cm) (Class IIa LOE B) with chest compression and chest recoilrelaxation times approximately equal (Class IIb LOE C)

Compression DEPTH

Target = 38-51 mm with complete release Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Complete RELEASERECOIL (Full)

Complete Recoil essential to reduce intrathoracic pressure between compressions

Reducing recoil improves hemodynamics in arrest and improves Coronary Perfusion Pressure (CPP)

Incomplete chest wall recoil can be reduced during CPR by using electronic recording devices that provide real-time feedback

Niles D Nysaether J Sutton R Nishisaki A Abella BS Arbogast K Maltese MR Berg RA Helfaer M Nadkarni V Leaning is common during in-hospital

pediatric CPR and decreased with automated corrective feedback Resuscitation 200980553ndash557

Intra-thoracic Pressure and CPR

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and Recoil

Abella et al 2005 Circulation

INTURRUPTIONS

Pausing for procedures intubation IV pulse check etc)

Pausing for rhythm analysis Pausing after shock to await post-

shock rhythm Pausing to charge clear and shock Unaware of importance of CPR in

ldquobig picturerdquo

No-Flow Ratio (Interruption of CPR)

Target = less than 20 Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

KEY POINT

ldquohellipHigh-quality CPR is important not only at the onset but throughout the course of resuscitation Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPRrdquo

AHA 2010 Guidelines

DECREASING VENTILATION

CPR with Advanced Airway 8 ndash 10 breathsminute

Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

90 of all changes to 2010 ECC are right in the BLS segment

Builds on and further enhances the changes and research discussed in the 2005 guidelines

COMPRESSIONS are the single most emphasized segment of resuscitation

GOOD and SUSTAINED Coronary Perfusion Pressure is the GOAL

Understanding CPP

Coronary Perfusion Pressure (CPP) is essential to ROSC

When arrest is present for more than a few minutes the myocardium is depleted of oxygen and metabolic substrates

A brief period of (good and sustained) chest compressions can deliver oxygen and energy substrates (ie ATP) increasing the likelihood that a shock may terminate VF (defibrillation) and a perfusing rhythm will return (ie ROSC)

Without this a shock may result in ldquoSECONDARY ASYSTOLErdquo

GOOD and SUSTAINED CPP results in higher levels of myocardial ATP and survival

3 Phase Model

Understanding Coronary Perfusion Pressure

Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure

ROSC Associated with CPP

Overview of ECC 2010 Changes

Hands Only CPR

Single biggest change ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons

Hands Only CPR

Of note some healthcare providers and laypersons indicate that reluctance to perform mouth-to-mouth ventilation for victims of cardiac arrest is a theoretical and potential barrier to performing bystander CPR

When actual bystanders were interviewed however such reluctance was not expressed panic was cited as the major obstacle to laypersons performance of bystander CPR

The simpler Hands-Only technique may help overcome panic and hesitation to act in both regards

KEY POINT

HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR in LAY RESCUERS

This presumes that traditional CPR with ventilation will eventually be performed

The exact interval in which hands only CPR is more beneficial over traditional CPR is not known

CAB

Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

Confusion in Agonal Respirations vs Good Respirations

The rescuer should treat the victim who has occasional gasps as if he or she is not breathing (Class ILOE C)

The HCP will combine their assessment for respirations with assessment for responsiveness

The Layperson will assume that if the patient is completely unresponsive they have ineffective respirations

A simultaneous choreographed approach Much more emphasis on the team approach and a realistic

recognition of what and how PARAMEDICS do their job

Recognition that resuscitation is not a ldquolinierrdquo process (Step A THEN Step B etc) but a simultaneous series of actions

ldquohellipin a highly specialized environment such as a critical care unit of a hospital many of the individual components of CPR (compression-ventilation-defibrillation) may be managed simultaneously This approach requires choreography among many highly-trained rescuers who work as an integrated team

In the pre-hospital setting the order of the CPR components performed by the healthcare provider may switch between a sequenced and choreographed model depending on the proficiency of the provider and the availability of resourcesrdquo

- Circulation 2010122[suppl 3]S676 ndashS684

ldquo It is reasonable for healthcare providers to tailor the sequence of rescue actions to the most likely cause of arrestrdquo

THIS MEANS NO MORE COOK-BOOK MEDICINE

New CPR Guidelines

Traditional Healthcare Version

2005 to 2010 changes

Component of CPR

2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

PULSE CHECK HCP Only HCP only Checking for ldquoDEFNITE pulserdquo

SOME THINGS REMAIN IMPORTANTSOME THINGS REMAIN IMPORTANT

RATERATE

DEPTHDEPTH

RELEASERELEASE

UNINTERRUPTEDUNINTERRUPTED

DECREASED DECREASED VENTILATIONVENTILATION

5 KEY5 KEY ASPECTSASPECTS

OFOF GOODGOOD CPRCPR

Compression Rate (at least 100 Minute)

Rate per minute is NOT a function of ldquospeedrdquo of compressions only but a function of both speed ands minimizing no-flow periods (discussed later) for a total compressionsminute

Compressions rates as high as 130 resulted in favorable outcomes

Compression rates lt87minute saw rapid drop off in ROSC

NEW RECOMMENDATION At LEAST 100minute

Better too fast than too slow

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

76

75

58

42

Compression Rate

Target = ~100min with complete release Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH (At least 2 inches)

Previous studies show that only about 27 of compressions were deep enough (Wik 2005)

0 (none) were too deep NEW GIUDELINES The adult sternum

should be depressed at least 2 inches (5 cm) (Class IIa LOE B) with chest compression and chest recoilrelaxation times approximately equal (Class IIb LOE C)

Compression DEPTH

Target = 38-51 mm with complete release Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Complete RELEASERECOIL (Full)

Complete Recoil essential to reduce intrathoracic pressure between compressions

Reducing recoil improves hemodynamics in arrest and improves Coronary Perfusion Pressure (CPP)

Incomplete chest wall recoil can be reduced during CPR by using electronic recording devices that provide real-time feedback

Niles D Nysaether J Sutton R Nishisaki A Abella BS Arbogast K Maltese MR Berg RA Helfaer M Nadkarni V Leaning is common during in-hospital

pediatric CPR and decreased with automated corrective feedback Resuscitation 200980553ndash557

Intra-thoracic Pressure and CPR

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and Recoil

Abella et al 2005 Circulation

INTURRUPTIONS

Pausing for procedures intubation IV pulse check etc)

Pausing for rhythm analysis Pausing after shock to await post-

shock rhythm Pausing to charge clear and shock Unaware of importance of CPR in

ldquobig picturerdquo

No-Flow Ratio (Interruption of CPR)

Target = less than 20 Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

KEY POINT

ldquohellipHigh-quality CPR is important not only at the onset but throughout the course of resuscitation Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPRrdquo

AHA 2010 Guidelines

DECREASING VENTILATION

CPR with Advanced Airway 8 ndash 10 breathsminute

Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Understanding CPP

Coronary Perfusion Pressure (CPP) is essential to ROSC

When arrest is present for more than a few minutes the myocardium is depleted of oxygen and metabolic substrates

A brief period of (good and sustained) chest compressions can deliver oxygen and energy substrates (ie ATP) increasing the likelihood that a shock may terminate VF (defibrillation) and a perfusing rhythm will return (ie ROSC)

Without this a shock may result in ldquoSECONDARY ASYSTOLErdquo

GOOD and SUSTAINED CPP results in higher levels of myocardial ATP and survival

3 Phase Model

Understanding Coronary Perfusion Pressure

Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure

ROSC Associated with CPP

Overview of ECC 2010 Changes

Hands Only CPR

Single biggest change ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons

Hands Only CPR

Of note some healthcare providers and laypersons indicate that reluctance to perform mouth-to-mouth ventilation for victims of cardiac arrest is a theoretical and potential barrier to performing bystander CPR

When actual bystanders were interviewed however such reluctance was not expressed panic was cited as the major obstacle to laypersons performance of bystander CPR

The simpler Hands-Only technique may help overcome panic and hesitation to act in both regards

KEY POINT

HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR in LAY RESCUERS

This presumes that traditional CPR with ventilation will eventually be performed

The exact interval in which hands only CPR is more beneficial over traditional CPR is not known

CAB

Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

Confusion in Agonal Respirations vs Good Respirations

The rescuer should treat the victim who has occasional gasps as if he or she is not breathing (Class ILOE C)

The HCP will combine their assessment for respirations with assessment for responsiveness

The Layperson will assume that if the patient is completely unresponsive they have ineffective respirations

A simultaneous choreographed approach Much more emphasis on the team approach and a realistic

recognition of what and how PARAMEDICS do their job

Recognition that resuscitation is not a ldquolinierrdquo process (Step A THEN Step B etc) but a simultaneous series of actions

ldquohellipin a highly specialized environment such as a critical care unit of a hospital many of the individual components of CPR (compression-ventilation-defibrillation) may be managed simultaneously This approach requires choreography among many highly-trained rescuers who work as an integrated team

In the pre-hospital setting the order of the CPR components performed by the healthcare provider may switch between a sequenced and choreographed model depending on the proficiency of the provider and the availability of resourcesrdquo

- Circulation 2010122[suppl 3]S676 ndashS684

ldquo It is reasonable for healthcare providers to tailor the sequence of rescue actions to the most likely cause of arrestrdquo

THIS MEANS NO MORE COOK-BOOK MEDICINE

New CPR Guidelines

Traditional Healthcare Version

2005 to 2010 changes

Component of CPR

2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

PULSE CHECK HCP Only HCP only Checking for ldquoDEFNITE pulserdquo

SOME THINGS REMAIN IMPORTANTSOME THINGS REMAIN IMPORTANT

RATERATE

DEPTHDEPTH

RELEASERELEASE

UNINTERRUPTEDUNINTERRUPTED

DECREASED DECREASED VENTILATIONVENTILATION

5 KEY5 KEY ASPECTSASPECTS

OFOF GOODGOOD CPRCPR

Compression Rate (at least 100 Minute)

Rate per minute is NOT a function of ldquospeedrdquo of compressions only but a function of both speed ands minimizing no-flow periods (discussed later) for a total compressionsminute

Compressions rates as high as 130 resulted in favorable outcomes

Compression rates lt87minute saw rapid drop off in ROSC

NEW RECOMMENDATION At LEAST 100minute

Better too fast than too slow

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

76

75

58

42

Compression Rate

Target = ~100min with complete release Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH (At least 2 inches)

Previous studies show that only about 27 of compressions were deep enough (Wik 2005)

0 (none) were too deep NEW GIUDELINES The adult sternum

should be depressed at least 2 inches (5 cm) (Class IIa LOE B) with chest compression and chest recoilrelaxation times approximately equal (Class IIb LOE C)

Compression DEPTH

Target = 38-51 mm with complete release Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Complete RELEASERECOIL (Full)

Complete Recoil essential to reduce intrathoracic pressure between compressions

Reducing recoil improves hemodynamics in arrest and improves Coronary Perfusion Pressure (CPP)

Incomplete chest wall recoil can be reduced during CPR by using electronic recording devices that provide real-time feedback

Niles D Nysaether J Sutton R Nishisaki A Abella BS Arbogast K Maltese MR Berg RA Helfaer M Nadkarni V Leaning is common during in-hospital

pediatric CPR and decreased with automated corrective feedback Resuscitation 200980553ndash557

Intra-thoracic Pressure and CPR

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and Recoil

Abella et al 2005 Circulation

INTURRUPTIONS

Pausing for procedures intubation IV pulse check etc)

Pausing for rhythm analysis Pausing after shock to await post-

shock rhythm Pausing to charge clear and shock Unaware of importance of CPR in

ldquobig picturerdquo

No-Flow Ratio (Interruption of CPR)

Target = less than 20 Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

KEY POINT

ldquohellipHigh-quality CPR is important not only at the onset but throughout the course of resuscitation Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPRrdquo

AHA 2010 Guidelines

DECREASING VENTILATION

CPR with Advanced Airway 8 ndash 10 breathsminute

Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

3 Phase Model

Understanding Coronary Perfusion Pressure

Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure

ROSC Associated with CPP

Overview of ECC 2010 Changes

Hands Only CPR

Single biggest change ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons

Hands Only CPR

Of note some healthcare providers and laypersons indicate that reluctance to perform mouth-to-mouth ventilation for victims of cardiac arrest is a theoretical and potential barrier to performing bystander CPR

When actual bystanders were interviewed however such reluctance was not expressed panic was cited as the major obstacle to laypersons performance of bystander CPR

The simpler Hands-Only technique may help overcome panic and hesitation to act in both regards

KEY POINT

HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR in LAY RESCUERS

This presumes that traditional CPR with ventilation will eventually be performed

The exact interval in which hands only CPR is more beneficial over traditional CPR is not known

CAB

Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

Confusion in Agonal Respirations vs Good Respirations

The rescuer should treat the victim who has occasional gasps as if he or she is not breathing (Class ILOE C)

The HCP will combine their assessment for respirations with assessment for responsiveness

The Layperson will assume that if the patient is completely unresponsive they have ineffective respirations

A simultaneous choreographed approach Much more emphasis on the team approach and a realistic

recognition of what and how PARAMEDICS do their job

Recognition that resuscitation is not a ldquolinierrdquo process (Step A THEN Step B etc) but a simultaneous series of actions

ldquohellipin a highly specialized environment such as a critical care unit of a hospital many of the individual components of CPR (compression-ventilation-defibrillation) may be managed simultaneously This approach requires choreography among many highly-trained rescuers who work as an integrated team

In the pre-hospital setting the order of the CPR components performed by the healthcare provider may switch between a sequenced and choreographed model depending on the proficiency of the provider and the availability of resourcesrdquo

- Circulation 2010122[suppl 3]S676 ndashS684

ldquo It is reasonable for healthcare providers to tailor the sequence of rescue actions to the most likely cause of arrestrdquo

THIS MEANS NO MORE COOK-BOOK MEDICINE

New CPR Guidelines

Traditional Healthcare Version

2005 to 2010 changes

Component of CPR

2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

PULSE CHECK HCP Only HCP only Checking for ldquoDEFNITE pulserdquo

SOME THINGS REMAIN IMPORTANTSOME THINGS REMAIN IMPORTANT

RATERATE

DEPTHDEPTH

RELEASERELEASE

UNINTERRUPTEDUNINTERRUPTED

DECREASED DECREASED VENTILATIONVENTILATION

5 KEY5 KEY ASPECTSASPECTS

OFOF GOODGOOD CPRCPR

Compression Rate (at least 100 Minute)

Rate per minute is NOT a function of ldquospeedrdquo of compressions only but a function of both speed ands minimizing no-flow periods (discussed later) for a total compressionsminute

Compressions rates as high as 130 resulted in favorable outcomes

Compression rates lt87minute saw rapid drop off in ROSC

NEW RECOMMENDATION At LEAST 100minute

Better too fast than too slow

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

76

75

58

42

Compression Rate

Target = ~100min with complete release Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH (At least 2 inches)

Previous studies show that only about 27 of compressions were deep enough (Wik 2005)

0 (none) were too deep NEW GIUDELINES The adult sternum

should be depressed at least 2 inches (5 cm) (Class IIa LOE B) with chest compression and chest recoilrelaxation times approximately equal (Class IIb LOE C)

Compression DEPTH

Target = 38-51 mm with complete release Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Complete RELEASERECOIL (Full)

Complete Recoil essential to reduce intrathoracic pressure between compressions

Reducing recoil improves hemodynamics in arrest and improves Coronary Perfusion Pressure (CPP)

Incomplete chest wall recoil can be reduced during CPR by using electronic recording devices that provide real-time feedback

Niles D Nysaether J Sutton R Nishisaki A Abella BS Arbogast K Maltese MR Berg RA Helfaer M Nadkarni V Leaning is common during in-hospital

pediatric CPR and decreased with automated corrective feedback Resuscitation 200980553ndash557

Intra-thoracic Pressure and CPR

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and Recoil

Abella et al 2005 Circulation

INTURRUPTIONS

Pausing for procedures intubation IV pulse check etc)

Pausing for rhythm analysis Pausing after shock to await post-

shock rhythm Pausing to charge clear and shock Unaware of importance of CPR in

ldquobig picturerdquo

No-Flow Ratio (Interruption of CPR)

Target = less than 20 Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

KEY POINT

ldquohellipHigh-quality CPR is important not only at the onset but throughout the course of resuscitation Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPRrdquo

AHA 2010 Guidelines

DECREASING VENTILATION

CPR with Advanced Airway 8 ndash 10 breathsminute

Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Understanding Coronary Perfusion Pressure

Note this is Aortic Pressure CPP is ldquoroughlyrdquo half Aortic Pressure

ROSC Associated with CPP

Overview of ECC 2010 Changes

Hands Only CPR

Single biggest change ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons

Hands Only CPR

Of note some healthcare providers and laypersons indicate that reluctance to perform mouth-to-mouth ventilation for victims of cardiac arrest is a theoretical and potential barrier to performing bystander CPR

When actual bystanders were interviewed however such reluctance was not expressed panic was cited as the major obstacle to laypersons performance of bystander CPR

The simpler Hands-Only technique may help overcome panic and hesitation to act in both regards

KEY POINT

HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR in LAY RESCUERS

This presumes that traditional CPR with ventilation will eventually be performed

The exact interval in which hands only CPR is more beneficial over traditional CPR is not known

CAB

Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

Confusion in Agonal Respirations vs Good Respirations

The rescuer should treat the victim who has occasional gasps as if he or she is not breathing (Class ILOE C)

The HCP will combine their assessment for respirations with assessment for responsiveness

The Layperson will assume that if the patient is completely unresponsive they have ineffective respirations

A simultaneous choreographed approach Much more emphasis on the team approach and a realistic

recognition of what and how PARAMEDICS do their job

Recognition that resuscitation is not a ldquolinierrdquo process (Step A THEN Step B etc) but a simultaneous series of actions

ldquohellipin a highly specialized environment such as a critical care unit of a hospital many of the individual components of CPR (compression-ventilation-defibrillation) may be managed simultaneously This approach requires choreography among many highly-trained rescuers who work as an integrated team

In the pre-hospital setting the order of the CPR components performed by the healthcare provider may switch between a sequenced and choreographed model depending on the proficiency of the provider and the availability of resourcesrdquo

- Circulation 2010122[suppl 3]S676 ndashS684

ldquo It is reasonable for healthcare providers to tailor the sequence of rescue actions to the most likely cause of arrestrdquo

THIS MEANS NO MORE COOK-BOOK MEDICINE

New CPR Guidelines

Traditional Healthcare Version

2005 to 2010 changes

Component of CPR

2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

PULSE CHECK HCP Only HCP only Checking for ldquoDEFNITE pulserdquo

SOME THINGS REMAIN IMPORTANTSOME THINGS REMAIN IMPORTANT

RATERATE

DEPTHDEPTH

RELEASERELEASE

UNINTERRUPTEDUNINTERRUPTED

DECREASED DECREASED VENTILATIONVENTILATION

5 KEY5 KEY ASPECTSASPECTS

OFOF GOODGOOD CPRCPR

Compression Rate (at least 100 Minute)

Rate per minute is NOT a function of ldquospeedrdquo of compressions only but a function of both speed ands minimizing no-flow periods (discussed later) for a total compressionsminute

Compressions rates as high as 130 resulted in favorable outcomes

Compression rates lt87minute saw rapid drop off in ROSC

NEW RECOMMENDATION At LEAST 100minute

Better too fast than too slow

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

76

75

58

42

Compression Rate

Target = ~100min with complete release Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH (At least 2 inches)

Previous studies show that only about 27 of compressions were deep enough (Wik 2005)

0 (none) were too deep NEW GIUDELINES The adult sternum

should be depressed at least 2 inches (5 cm) (Class IIa LOE B) with chest compression and chest recoilrelaxation times approximately equal (Class IIb LOE C)

Compression DEPTH

Target = 38-51 mm with complete release Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Complete RELEASERECOIL (Full)

Complete Recoil essential to reduce intrathoracic pressure between compressions

Reducing recoil improves hemodynamics in arrest and improves Coronary Perfusion Pressure (CPP)

Incomplete chest wall recoil can be reduced during CPR by using electronic recording devices that provide real-time feedback

Niles D Nysaether J Sutton R Nishisaki A Abella BS Arbogast K Maltese MR Berg RA Helfaer M Nadkarni V Leaning is common during in-hospital

pediatric CPR and decreased with automated corrective feedback Resuscitation 200980553ndash557

Intra-thoracic Pressure and CPR

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and Recoil

Abella et al 2005 Circulation

INTURRUPTIONS

Pausing for procedures intubation IV pulse check etc)

Pausing for rhythm analysis Pausing after shock to await post-

shock rhythm Pausing to charge clear and shock Unaware of importance of CPR in

ldquobig picturerdquo

No-Flow Ratio (Interruption of CPR)

Target = less than 20 Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

KEY POINT

ldquohellipHigh-quality CPR is important not only at the onset but throughout the course of resuscitation Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPRrdquo

AHA 2010 Guidelines

DECREASING VENTILATION

CPR with Advanced Airway 8 ndash 10 breathsminute

Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

ROSC Associated with CPP

Overview of ECC 2010 Changes

Hands Only CPR

Single biggest change ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons

Hands Only CPR

Of note some healthcare providers and laypersons indicate that reluctance to perform mouth-to-mouth ventilation for victims of cardiac arrest is a theoretical and potential barrier to performing bystander CPR

When actual bystanders were interviewed however such reluctance was not expressed panic was cited as the major obstacle to laypersons performance of bystander CPR

The simpler Hands-Only technique may help overcome panic and hesitation to act in both regards

KEY POINT

HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR in LAY RESCUERS

This presumes that traditional CPR with ventilation will eventually be performed

The exact interval in which hands only CPR is more beneficial over traditional CPR is not known

CAB

Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

Confusion in Agonal Respirations vs Good Respirations

The rescuer should treat the victim who has occasional gasps as if he or she is not breathing (Class ILOE C)

The HCP will combine their assessment for respirations with assessment for responsiveness

The Layperson will assume that if the patient is completely unresponsive they have ineffective respirations

A simultaneous choreographed approach Much more emphasis on the team approach and a realistic

recognition of what and how PARAMEDICS do their job

Recognition that resuscitation is not a ldquolinierrdquo process (Step A THEN Step B etc) but a simultaneous series of actions

ldquohellipin a highly specialized environment such as a critical care unit of a hospital many of the individual components of CPR (compression-ventilation-defibrillation) may be managed simultaneously This approach requires choreography among many highly-trained rescuers who work as an integrated team

In the pre-hospital setting the order of the CPR components performed by the healthcare provider may switch between a sequenced and choreographed model depending on the proficiency of the provider and the availability of resourcesrdquo

- Circulation 2010122[suppl 3]S676 ndashS684

ldquo It is reasonable for healthcare providers to tailor the sequence of rescue actions to the most likely cause of arrestrdquo

THIS MEANS NO MORE COOK-BOOK MEDICINE

New CPR Guidelines

Traditional Healthcare Version

2005 to 2010 changes

Component of CPR

2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

PULSE CHECK HCP Only HCP only Checking for ldquoDEFNITE pulserdquo

SOME THINGS REMAIN IMPORTANTSOME THINGS REMAIN IMPORTANT

RATERATE

DEPTHDEPTH

RELEASERELEASE

UNINTERRUPTEDUNINTERRUPTED

DECREASED DECREASED VENTILATIONVENTILATION

5 KEY5 KEY ASPECTSASPECTS

OFOF GOODGOOD CPRCPR

Compression Rate (at least 100 Minute)

Rate per minute is NOT a function of ldquospeedrdquo of compressions only but a function of both speed ands minimizing no-flow periods (discussed later) for a total compressionsminute

Compressions rates as high as 130 resulted in favorable outcomes

Compression rates lt87minute saw rapid drop off in ROSC

NEW RECOMMENDATION At LEAST 100minute

Better too fast than too slow

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

76

75

58

42

Compression Rate

Target = ~100min with complete release Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH (At least 2 inches)

Previous studies show that only about 27 of compressions were deep enough (Wik 2005)

0 (none) were too deep NEW GIUDELINES The adult sternum

should be depressed at least 2 inches (5 cm) (Class IIa LOE B) with chest compression and chest recoilrelaxation times approximately equal (Class IIb LOE C)

Compression DEPTH

Target = 38-51 mm with complete release Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Complete RELEASERECOIL (Full)

Complete Recoil essential to reduce intrathoracic pressure between compressions

Reducing recoil improves hemodynamics in arrest and improves Coronary Perfusion Pressure (CPP)

Incomplete chest wall recoil can be reduced during CPR by using electronic recording devices that provide real-time feedback

Niles D Nysaether J Sutton R Nishisaki A Abella BS Arbogast K Maltese MR Berg RA Helfaer M Nadkarni V Leaning is common during in-hospital

pediatric CPR and decreased with automated corrective feedback Resuscitation 200980553ndash557

Intra-thoracic Pressure and CPR

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and Recoil

Abella et al 2005 Circulation

INTURRUPTIONS

Pausing for procedures intubation IV pulse check etc)

Pausing for rhythm analysis Pausing after shock to await post-

shock rhythm Pausing to charge clear and shock Unaware of importance of CPR in

ldquobig picturerdquo

No-Flow Ratio (Interruption of CPR)

Target = less than 20 Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

KEY POINT

ldquohellipHigh-quality CPR is important not only at the onset but throughout the course of resuscitation Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPRrdquo

AHA 2010 Guidelines

DECREASING VENTILATION

CPR with Advanced Airway 8 ndash 10 breathsminute

Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Overview of ECC 2010 Changes

Hands Only CPR

Single biggest change ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons

Hands Only CPR

Of note some healthcare providers and laypersons indicate that reluctance to perform mouth-to-mouth ventilation for victims of cardiac arrest is a theoretical and potential barrier to performing bystander CPR

When actual bystanders were interviewed however such reluctance was not expressed panic was cited as the major obstacle to laypersons performance of bystander CPR

The simpler Hands-Only technique may help overcome panic and hesitation to act in both regards

KEY POINT

HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR in LAY RESCUERS

This presumes that traditional CPR with ventilation will eventually be performed

The exact interval in which hands only CPR is more beneficial over traditional CPR is not known

CAB

Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

Confusion in Agonal Respirations vs Good Respirations

The rescuer should treat the victim who has occasional gasps as if he or she is not breathing (Class ILOE C)

The HCP will combine their assessment for respirations with assessment for responsiveness

The Layperson will assume that if the patient is completely unresponsive they have ineffective respirations

A simultaneous choreographed approach Much more emphasis on the team approach and a realistic

recognition of what and how PARAMEDICS do their job

Recognition that resuscitation is not a ldquolinierrdquo process (Step A THEN Step B etc) but a simultaneous series of actions

ldquohellipin a highly specialized environment such as a critical care unit of a hospital many of the individual components of CPR (compression-ventilation-defibrillation) may be managed simultaneously This approach requires choreography among many highly-trained rescuers who work as an integrated team

In the pre-hospital setting the order of the CPR components performed by the healthcare provider may switch between a sequenced and choreographed model depending on the proficiency of the provider and the availability of resourcesrdquo

- Circulation 2010122[suppl 3]S676 ndashS684

ldquo It is reasonable for healthcare providers to tailor the sequence of rescue actions to the most likely cause of arrestrdquo

THIS MEANS NO MORE COOK-BOOK MEDICINE

New CPR Guidelines

Traditional Healthcare Version

2005 to 2010 changes

Component of CPR

2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

PULSE CHECK HCP Only HCP only Checking for ldquoDEFNITE pulserdquo

SOME THINGS REMAIN IMPORTANTSOME THINGS REMAIN IMPORTANT

RATERATE

DEPTHDEPTH

RELEASERELEASE

UNINTERRUPTEDUNINTERRUPTED

DECREASED DECREASED VENTILATIONVENTILATION

5 KEY5 KEY ASPECTSASPECTS

OFOF GOODGOOD CPRCPR

Compression Rate (at least 100 Minute)

Rate per minute is NOT a function of ldquospeedrdquo of compressions only but a function of both speed ands minimizing no-flow periods (discussed later) for a total compressionsminute

Compressions rates as high as 130 resulted in favorable outcomes

Compression rates lt87minute saw rapid drop off in ROSC

NEW RECOMMENDATION At LEAST 100minute

Better too fast than too slow

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

76

75

58

42

Compression Rate

Target = ~100min with complete release Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH (At least 2 inches)

Previous studies show that only about 27 of compressions were deep enough (Wik 2005)

0 (none) were too deep NEW GIUDELINES The adult sternum

should be depressed at least 2 inches (5 cm) (Class IIa LOE B) with chest compression and chest recoilrelaxation times approximately equal (Class IIb LOE C)

Compression DEPTH

Target = 38-51 mm with complete release Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Complete RELEASERECOIL (Full)

Complete Recoil essential to reduce intrathoracic pressure between compressions

Reducing recoil improves hemodynamics in arrest and improves Coronary Perfusion Pressure (CPP)

Incomplete chest wall recoil can be reduced during CPR by using electronic recording devices that provide real-time feedback

Niles D Nysaether J Sutton R Nishisaki A Abella BS Arbogast K Maltese MR Berg RA Helfaer M Nadkarni V Leaning is common during in-hospital

pediatric CPR and decreased with automated corrective feedback Resuscitation 200980553ndash557

Intra-thoracic Pressure and CPR

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and Recoil

Abella et al 2005 Circulation

INTURRUPTIONS

Pausing for procedures intubation IV pulse check etc)

Pausing for rhythm analysis Pausing after shock to await post-

shock rhythm Pausing to charge clear and shock Unaware of importance of CPR in

ldquobig picturerdquo

No-Flow Ratio (Interruption of CPR)

Target = less than 20 Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

KEY POINT

ldquohellipHigh-quality CPR is important not only at the onset but throughout the course of resuscitation Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPRrdquo

AHA 2010 Guidelines

DECREASING VENTILATION

CPR with Advanced Airway 8 ndash 10 breathsminute

Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Hands Only CPR

Single biggest change ldquoHands Only CPRrdquo AKA

Compression only CPR for lay persons

Hands Only CPR

Of note some healthcare providers and laypersons indicate that reluctance to perform mouth-to-mouth ventilation for victims of cardiac arrest is a theoretical and potential barrier to performing bystander CPR

When actual bystanders were interviewed however such reluctance was not expressed panic was cited as the major obstacle to laypersons performance of bystander CPR

The simpler Hands-Only technique may help overcome panic and hesitation to act in both regards

KEY POINT

HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR in LAY RESCUERS

This presumes that traditional CPR with ventilation will eventually be performed

The exact interval in which hands only CPR is more beneficial over traditional CPR is not known

CAB

Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

Confusion in Agonal Respirations vs Good Respirations

The rescuer should treat the victim who has occasional gasps as if he or she is not breathing (Class ILOE C)

The HCP will combine their assessment for respirations with assessment for responsiveness

The Layperson will assume that if the patient is completely unresponsive they have ineffective respirations

A simultaneous choreographed approach Much more emphasis on the team approach and a realistic

recognition of what and how PARAMEDICS do their job

Recognition that resuscitation is not a ldquolinierrdquo process (Step A THEN Step B etc) but a simultaneous series of actions

ldquohellipin a highly specialized environment such as a critical care unit of a hospital many of the individual components of CPR (compression-ventilation-defibrillation) may be managed simultaneously This approach requires choreography among many highly-trained rescuers who work as an integrated team

In the pre-hospital setting the order of the CPR components performed by the healthcare provider may switch between a sequenced and choreographed model depending on the proficiency of the provider and the availability of resourcesrdquo

- Circulation 2010122[suppl 3]S676 ndashS684

ldquo It is reasonable for healthcare providers to tailor the sequence of rescue actions to the most likely cause of arrestrdquo

THIS MEANS NO MORE COOK-BOOK MEDICINE

New CPR Guidelines

Traditional Healthcare Version

2005 to 2010 changes

Component of CPR

2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

PULSE CHECK HCP Only HCP only Checking for ldquoDEFNITE pulserdquo

SOME THINGS REMAIN IMPORTANTSOME THINGS REMAIN IMPORTANT

RATERATE

DEPTHDEPTH

RELEASERELEASE

UNINTERRUPTEDUNINTERRUPTED

DECREASED DECREASED VENTILATIONVENTILATION

5 KEY5 KEY ASPECTSASPECTS

OFOF GOODGOOD CPRCPR

Compression Rate (at least 100 Minute)

Rate per minute is NOT a function of ldquospeedrdquo of compressions only but a function of both speed ands minimizing no-flow periods (discussed later) for a total compressionsminute

Compressions rates as high as 130 resulted in favorable outcomes

Compression rates lt87minute saw rapid drop off in ROSC

NEW RECOMMENDATION At LEAST 100minute

Better too fast than too slow

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

76

75

58

42

Compression Rate

Target = ~100min with complete release Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH (At least 2 inches)

Previous studies show that only about 27 of compressions were deep enough (Wik 2005)

0 (none) were too deep NEW GIUDELINES The adult sternum

should be depressed at least 2 inches (5 cm) (Class IIa LOE B) with chest compression and chest recoilrelaxation times approximately equal (Class IIb LOE C)

Compression DEPTH

Target = 38-51 mm with complete release Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Complete RELEASERECOIL (Full)

Complete Recoil essential to reduce intrathoracic pressure between compressions

Reducing recoil improves hemodynamics in arrest and improves Coronary Perfusion Pressure (CPP)

Incomplete chest wall recoil can be reduced during CPR by using electronic recording devices that provide real-time feedback

Niles D Nysaether J Sutton R Nishisaki A Abella BS Arbogast K Maltese MR Berg RA Helfaer M Nadkarni V Leaning is common during in-hospital

pediatric CPR and decreased with automated corrective feedback Resuscitation 200980553ndash557

Intra-thoracic Pressure and CPR

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and Recoil

Abella et al 2005 Circulation

INTURRUPTIONS

Pausing for procedures intubation IV pulse check etc)

Pausing for rhythm analysis Pausing after shock to await post-

shock rhythm Pausing to charge clear and shock Unaware of importance of CPR in

ldquobig picturerdquo

No-Flow Ratio (Interruption of CPR)

Target = less than 20 Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

KEY POINT

ldquohellipHigh-quality CPR is important not only at the onset but throughout the course of resuscitation Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPRrdquo

AHA 2010 Guidelines

DECREASING VENTILATION

CPR with Advanced Airway 8 ndash 10 breathsminute

Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Hands Only CPR

Of note some healthcare providers and laypersons indicate that reluctance to perform mouth-to-mouth ventilation for victims of cardiac arrest is a theoretical and potential barrier to performing bystander CPR

When actual bystanders were interviewed however such reluctance was not expressed panic was cited as the major obstacle to laypersons performance of bystander CPR

The simpler Hands-Only technique may help overcome panic and hesitation to act in both regards

KEY POINT

HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR in LAY RESCUERS

This presumes that traditional CPR with ventilation will eventually be performed

The exact interval in which hands only CPR is more beneficial over traditional CPR is not known

CAB

Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

Confusion in Agonal Respirations vs Good Respirations

The rescuer should treat the victim who has occasional gasps as if he or she is not breathing (Class ILOE C)

The HCP will combine their assessment for respirations with assessment for responsiveness

The Layperson will assume that if the patient is completely unresponsive they have ineffective respirations

A simultaneous choreographed approach Much more emphasis on the team approach and a realistic

recognition of what and how PARAMEDICS do their job

Recognition that resuscitation is not a ldquolinierrdquo process (Step A THEN Step B etc) but a simultaneous series of actions

ldquohellipin a highly specialized environment such as a critical care unit of a hospital many of the individual components of CPR (compression-ventilation-defibrillation) may be managed simultaneously This approach requires choreography among many highly-trained rescuers who work as an integrated team

In the pre-hospital setting the order of the CPR components performed by the healthcare provider may switch between a sequenced and choreographed model depending on the proficiency of the provider and the availability of resourcesrdquo

- Circulation 2010122[suppl 3]S676 ndashS684

ldquo It is reasonable for healthcare providers to tailor the sequence of rescue actions to the most likely cause of arrestrdquo

THIS MEANS NO MORE COOK-BOOK MEDICINE

New CPR Guidelines

Traditional Healthcare Version

2005 to 2010 changes

Component of CPR

2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

PULSE CHECK HCP Only HCP only Checking for ldquoDEFNITE pulserdquo

SOME THINGS REMAIN IMPORTANTSOME THINGS REMAIN IMPORTANT

RATERATE

DEPTHDEPTH

RELEASERELEASE

UNINTERRUPTEDUNINTERRUPTED

DECREASED DECREASED VENTILATIONVENTILATION

5 KEY5 KEY ASPECTSASPECTS

OFOF GOODGOOD CPRCPR

Compression Rate (at least 100 Minute)

Rate per minute is NOT a function of ldquospeedrdquo of compressions only but a function of both speed ands minimizing no-flow periods (discussed later) for a total compressionsminute

Compressions rates as high as 130 resulted in favorable outcomes

Compression rates lt87minute saw rapid drop off in ROSC

NEW RECOMMENDATION At LEAST 100minute

Better too fast than too slow

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

76

75

58

42

Compression Rate

Target = ~100min with complete release Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH (At least 2 inches)

Previous studies show that only about 27 of compressions were deep enough (Wik 2005)

0 (none) were too deep NEW GIUDELINES The adult sternum

should be depressed at least 2 inches (5 cm) (Class IIa LOE B) with chest compression and chest recoilrelaxation times approximately equal (Class IIb LOE C)

Compression DEPTH

Target = 38-51 mm with complete release Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Complete RELEASERECOIL (Full)

Complete Recoil essential to reduce intrathoracic pressure between compressions

Reducing recoil improves hemodynamics in arrest and improves Coronary Perfusion Pressure (CPP)

Incomplete chest wall recoil can be reduced during CPR by using electronic recording devices that provide real-time feedback

Niles D Nysaether J Sutton R Nishisaki A Abella BS Arbogast K Maltese MR Berg RA Helfaer M Nadkarni V Leaning is common during in-hospital

pediatric CPR and decreased with automated corrective feedback Resuscitation 200980553ndash557

Intra-thoracic Pressure and CPR

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and Recoil

Abella et al 2005 Circulation

INTURRUPTIONS

Pausing for procedures intubation IV pulse check etc)

Pausing for rhythm analysis Pausing after shock to await post-

shock rhythm Pausing to charge clear and shock Unaware of importance of CPR in

ldquobig picturerdquo

No-Flow Ratio (Interruption of CPR)

Target = less than 20 Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

KEY POINT

ldquohellipHigh-quality CPR is important not only at the onset but throughout the course of resuscitation Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPRrdquo

AHA 2010 Guidelines

DECREASING VENTILATION

CPR with Advanced Airway 8 ndash 10 breathsminute

Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

KEY POINT

HANDS ONLY CPR MAY IMPROVE ROSC BY 7 OVER TRADITIONAL CPR in LAY RESCUERS

This presumes that traditional CPR with ventilation will eventually be performed

The exact interval in which hands only CPR is more beneficial over traditional CPR is not known

CAB

Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

Confusion in Agonal Respirations vs Good Respirations

The rescuer should treat the victim who has occasional gasps as if he or she is not breathing (Class ILOE C)

The HCP will combine their assessment for respirations with assessment for responsiveness

The Layperson will assume that if the patient is completely unresponsive they have ineffective respirations

A simultaneous choreographed approach Much more emphasis on the team approach and a realistic

recognition of what and how PARAMEDICS do their job

Recognition that resuscitation is not a ldquolinierrdquo process (Step A THEN Step B etc) but a simultaneous series of actions

ldquohellipin a highly specialized environment such as a critical care unit of a hospital many of the individual components of CPR (compression-ventilation-defibrillation) may be managed simultaneously This approach requires choreography among many highly-trained rescuers who work as an integrated team

In the pre-hospital setting the order of the CPR components performed by the healthcare provider may switch between a sequenced and choreographed model depending on the proficiency of the provider and the availability of resourcesrdquo

- Circulation 2010122[suppl 3]S676 ndashS684

ldquo It is reasonable for healthcare providers to tailor the sequence of rescue actions to the most likely cause of arrestrdquo

THIS MEANS NO MORE COOK-BOOK MEDICINE

New CPR Guidelines

Traditional Healthcare Version

2005 to 2010 changes

Component of CPR

2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

PULSE CHECK HCP Only HCP only Checking for ldquoDEFNITE pulserdquo

SOME THINGS REMAIN IMPORTANTSOME THINGS REMAIN IMPORTANT

RATERATE

DEPTHDEPTH

RELEASERELEASE

UNINTERRUPTEDUNINTERRUPTED

DECREASED DECREASED VENTILATIONVENTILATION

5 KEY5 KEY ASPECTSASPECTS

OFOF GOODGOOD CPRCPR

Compression Rate (at least 100 Minute)

Rate per minute is NOT a function of ldquospeedrdquo of compressions only but a function of both speed ands minimizing no-flow periods (discussed later) for a total compressionsminute

Compressions rates as high as 130 resulted in favorable outcomes

Compression rates lt87minute saw rapid drop off in ROSC

NEW RECOMMENDATION At LEAST 100minute

Better too fast than too slow

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

76

75

58

42

Compression Rate

Target = ~100min with complete release Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH (At least 2 inches)

Previous studies show that only about 27 of compressions were deep enough (Wik 2005)

0 (none) were too deep NEW GIUDELINES The adult sternum

should be depressed at least 2 inches (5 cm) (Class IIa LOE B) with chest compression and chest recoilrelaxation times approximately equal (Class IIb LOE C)

Compression DEPTH

Target = 38-51 mm with complete release Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Complete RELEASERECOIL (Full)

Complete Recoil essential to reduce intrathoracic pressure between compressions

Reducing recoil improves hemodynamics in arrest and improves Coronary Perfusion Pressure (CPP)

Incomplete chest wall recoil can be reduced during CPR by using electronic recording devices that provide real-time feedback

Niles D Nysaether J Sutton R Nishisaki A Abella BS Arbogast K Maltese MR Berg RA Helfaer M Nadkarni V Leaning is common during in-hospital

pediatric CPR and decreased with automated corrective feedback Resuscitation 200980553ndash557

Intra-thoracic Pressure and CPR

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and Recoil

Abella et al 2005 Circulation

INTURRUPTIONS

Pausing for procedures intubation IV pulse check etc)

Pausing for rhythm analysis Pausing after shock to await post-

shock rhythm Pausing to charge clear and shock Unaware of importance of CPR in

ldquobig picturerdquo

No-Flow Ratio (Interruption of CPR)

Target = less than 20 Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

KEY POINT

ldquohellipHigh-quality CPR is important not only at the onset but throughout the course of resuscitation Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPRrdquo

AHA 2010 Guidelines

DECREASING VENTILATION

CPR with Advanced Airway 8 ndash 10 breathsminute

Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

CAB

Sequence change to chest compressions before rescue breaths (CAB rather than ABC)

This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds

This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock

Pulse Check

Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

Confusion in Agonal Respirations vs Good Respirations

The rescuer should treat the victim who has occasional gasps as if he or she is not breathing (Class ILOE C)

The HCP will combine their assessment for respirations with assessment for responsiveness

The Layperson will assume that if the patient is completely unresponsive they have ineffective respirations

A simultaneous choreographed approach Much more emphasis on the team approach and a realistic

recognition of what and how PARAMEDICS do their job

Recognition that resuscitation is not a ldquolinierrdquo process (Step A THEN Step B etc) but a simultaneous series of actions

ldquohellipin a highly specialized environment such as a critical care unit of a hospital many of the individual components of CPR (compression-ventilation-defibrillation) may be managed simultaneously This approach requires choreography among many highly-trained rescuers who work as an integrated team

In the pre-hospital setting the order of the CPR components performed by the healthcare provider may switch between a sequenced and choreographed model depending on the proficiency of the provider and the availability of resourcesrdquo

- Circulation 2010122[suppl 3]S676 ndashS684

ldquo It is reasonable for healthcare providers to tailor the sequence of rescue actions to the most likely cause of arrestrdquo

THIS MEANS NO MORE COOK-BOOK MEDICINE

New CPR Guidelines

Traditional Healthcare Version

2005 to 2010 changes

Component of CPR

2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

PULSE CHECK HCP Only HCP only Checking for ldquoDEFNITE pulserdquo

SOME THINGS REMAIN IMPORTANTSOME THINGS REMAIN IMPORTANT

RATERATE

DEPTHDEPTH

RELEASERELEASE

UNINTERRUPTEDUNINTERRUPTED

DECREASED DECREASED VENTILATIONVENTILATION

5 KEY5 KEY ASPECTSASPECTS

OFOF GOODGOOD CPRCPR

Compression Rate (at least 100 Minute)

Rate per minute is NOT a function of ldquospeedrdquo of compressions only but a function of both speed ands minimizing no-flow periods (discussed later) for a total compressionsminute

Compressions rates as high as 130 resulted in favorable outcomes

Compression rates lt87minute saw rapid drop off in ROSC

NEW RECOMMENDATION At LEAST 100minute

Better too fast than too slow

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

76

75

58

42

Compression Rate

Target = ~100min with complete release Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH (At least 2 inches)

Previous studies show that only about 27 of compressions were deep enough (Wik 2005)

0 (none) were too deep NEW GIUDELINES The adult sternum

should be depressed at least 2 inches (5 cm) (Class IIa LOE B) with chest compression and chest recoilrelaxation times approximately equal (Class IIb LOE C)

Compression DEPTH

Target = 38-51 mm with complete release Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Complete RELEASERECOIL (Full)

Complete Recoil essential to reduce intrathoracic pressure between compressions

Reducing recoil improves hemodynamics in arrest and improves Coronary Perfusion Pressure (CPP)

Incomplete chest wall recoil can be reduced during CPR by using electronic recording devices that provide real-time feedback

Niles D Nysaether J Sutton R Nishisaki A Abella BS Arbogast K Maltese MR Berg RA Helfaer M Nadkarni V Leaning is common during in-hospital

pediatric CPR and decreased with automated corrective feedback Resuscitation 200980553ndash557

Intra-thoracic Pressure and CPR

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and Recoil

Abella et al 2005 Circulation

INTURRUPTIONS

Pausing for procedures intubation IV pulse check etc)

Pausing for rhythm analysis Pausing after shock to await post-

shock rhythm Pausing to charge clear and shock Unaware of importance of CPR in

ldquobig picturerdquo

No-Flow Ratio (Interruption of CPR)

Target = less than 20 Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

KEY POINT

ldquohellipHigh-quality CPR is important not only at the onset but throughout the course of resuscitation Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPRrdquo

AHA 2010 Guidelines

DECREASING VENTILATION

CPR with Advanced Airway 8 ndash 10 breathsminute

Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Pulse Check

Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse

The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally

Healthcare providers also may take too long to check for a pulse The healthcare provider should take no more than 10 seconds to check for a pulse and if the rescuer does not definitely feel a pulse within that time period the rescuer should begin CPR

Look Listen and Feel

Confusion in Agonal Respirations vs Good Respirations

The rescuer should treat the victim who has occasional gasps as if he or she is not breathing (Class ILOE C)

The HCP will combine their assessment for respirations with assessment for responsiveness

The Layperson will assume that if the patient is completely unresponsive they have ineffective respirations

A simultaneous choreographed approach Much more emphasis on the team approach and a realistic

recognition of what and how PARAMEDICS do their job

Recognition that resuscitation is not a ldquolinierrdquo process (Step A THEN Step B etc) but a simultaneous series of actions

ldquohellipin a highly specialized environment such as a critical care unit of a hospital many of the individual components of CPR (compression-ventilation-defibrillation) may be managed simultaneously This approach requires choreography among many highly-trained rescuers who work as an integrated team

In the pre-hospital setting the order of the CPR components performed by the healthcare provider may switch between a sequenced and choreographed model depending on the proficiency of the provider and the availability of resourcesrdquo

- Circulation 2010122[suppl 3]S676 ndashS684

ldquo It is reasonable for healthcare providers to tailor the sequence of rescue actions to the most likely cause of arrestrdquo

THIS MEANS NO MORE COOK-BOOK MEDICINE

New CPR Guidelines

Traditional Healthcare Version

2005 to 2010 changes

Component of CPR

2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

PULSE CHECK HCP Only HCP only Checking for ldquoDEFNITE pulserdquo

SOME THINGS REMAIN IMPORTANTSOME THINGS REMAIN IMPORTANT

RATERATE

DEPTHDEPTH

RELEASERELEASE

UNINTERRUPTEDUNINTERRUPTED

DECREASED DECREASED VENTILATIONVENTILATION

5 KEY5 KEY ASPECTSASPECTS

OFOF GOODGOOD CPRCPR

Compression Rate (at least 100 Minute)

Rate per minute is NOT a function of ldquospeedrdquo of compressions only but a function of both speed ands minimizing no-flow periods (discussed later) for a total compressionsminute

Compressions rates as high as 130 resulted in favorable outcomes

Compression rates lt87minute saw rapid drop off in ROSC

NEW RECOMMENDATION At LEAST 100minute

Better too fast than too slow

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

76

75

58

42

Compression Rate

Target = ~100min with complete release Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH (At least 2 inches)

Previous studies show that only about 27 of compressions were deep enough (Wik 2005)

0 (none) were too deep NEW GIUDELINES The adult sternum

should be depressed at least 2 inches (5 cm) (Class IIa LOE B) with chest compression and chest recoilrelaxation times approximately equal (Class IIb LOE C)

Compression DEPTH

Target = 38-51 mm with complete release Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Complete RELEASERECOIL (Full)

Complete Recoil essential to reduce intrathoracic pressure between compressions

Reducing recoil improves hemodynamics in arrest and improves Coronary Perfusion Pressure (CPP)

Incomplete chest wall recoil can be reduced during CPR by using electronic recording devices that provide real-time feedback

Niles D Nysaether J Sutton R Nishisaki A Abella BS Arbogast K Maltese MR Berg RA Helfaer M Nadkarni V Leaning is common during in-hospital

pediatric CPR and decreased with automated corrective feedback Resuscitation 200980553ndash557

Intra-thoracic Pressure and CPR

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and Recoil

Abella et al 2005 Circulation

INTURRUPTIONS

Pausing for procedures intubation IV pulse check etc)

Pausing for rhythm analysis Pausing after shock to await post-

shock rhythm Pausing to charge clear and shock Unaware of importance of CPR in

ldquobig picturerdquo

No-Flow Ratio (Interruption of CPR)

Target = less than 20 Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

KEY POINT

ldquohellipHigh-quality CPR is important not only at the onset but throughout the course of resuscitation Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPRrdquo

AHA 2010 Guidelines

DECREASING VENTILATION

CPR with Advanced Airway 8 ndash 10 breathsminute

Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Look Listen and Feel

Confusion in Agonal Respirations vs Good Respirations

The rescuer should treat the victim who has occasional gasps as if he or she is not breathing (Class ILOE C)

The HCP will combine their assessment for respirations with assessment for responsiveness

The Layperson will assume that if the patient is completely unresponsive they have ineffective respirations

A simultaneous choreographed approach Much more emphasis on the team approach and a realistic

recognition of what and how PARAMEDICS do their job

Recognition that resuscitation is not a ldquolinierrdquo process (Step A THEN Step B etc) but a simultaneous series of actions

ldquohellipin a highly specialized environment such as a critical care unit of a hospital many of the individual components of CPR (compression-ventilation-defibrillation) may be managed simultaneously This approach requires choreography among many highly-trained rescuers who work as an integrated team

In the pre-hospital setting the order of the CPR components performed by the healthcare provider may switch between a sequenced and choreographed model depending on the proficiency of the provider and the availability of resourcesrdquo

- Circulation 2010122[suppl 3]S676 ndashS684

ldquo It is reasonable for healthcare providers to tailor the sequence of rescue actions to the most likely cause of arrestrdquo

THIS MEANS NO MORE COOK-BOOK MEDICINE

New CPR Guidelines

Traditional Healthcare Version

2005 to 2010 changes

Component of CPR

2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

PULSE CHECK HCP Only HCP only Checking for ldquoDEFNITE pulserdquo

SOME THINGS REMAIN IMPORTANTSOME THINGS REMAIN IMPORTANT

RATERATE

DEPTHDEPTH

RELEASERELEASE

UNINTERRUPTEDUNINTERRUPTED

DECREASED DECREASED VENTILATIONVENTILATION

5 KEY5 KEY ASPECTSASPECTS

OFOF GOODGOOD CPRCPR

Compression Rate (at least 100 Minute)

Rate per minute is NOT a function of ldquospeedrdquo of compressions only but a function of both speed ands minimizing no-flow periods (discussed later) for a total compressionsminute

Compressions rates as high as 130 resulted in favorable outcomes

Compression rates lt87minute saw rapid drop off in ROSC

NEW RECOMMENDATION At LEAST 100minute

Better too fast than too slow

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

76

75

58

42

Compression Rate

Target = ~100min with complete release Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH (At least 2 inches)

Previous studies show that only about 27 of compressions were deep enough (Wik 2005)

0 (none) were too deep NEW GIUDELINES The adult sternum

should be depressed at least 2 inches (5 cm) (Class IIa LOE B) with chest compression and chest recoilrelaxation times approximately equal (Class IIb LOE C)

Compression DEPTH

Target = 38-51 mm with complete release Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Complete RELEASERECOIL (Full)

Complete Recoil essential to reduce intrathoracic pressure between compressions

Reducing recoil improves hemodynamics in arrest and improves Coronary Perfusion Pressure (CPP)

Incomplete chest wall recoil can be reduced during CPR by using electronic recording devices that provide real-time feedback

Niles D Nysaether J Sutton R Nishisaki A Abella BS Arbogast K Maltese MR Berg RA Helfaer M Nadkarni V Leaning is common during in-hospital

pediatric CPR and decreased with automated corrective feedback Resuscitation 200980553ndash557

Intra-thoracic Pressure and CPR

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and Recoil

Abella et al 2005 Circulation

INTURRUPTIONS

Pausing for procedures intubation IV pulse check etc)

Pausing for rhythm analysis Pausing after shock to await post-

shock rhythm Pausing to charge clear and shock Unaware of importance of CPR in

ldquobig picturerdquo

No-Flow Ratio (Interruption of CPR)

Target = less than 20 Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

KEY POINT

ldquohellipHigh-quality CPR is important not only at the onset but throughout the course of resuscitation Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPRrdquo

AHA 2010 Guidelines

DECREASING VENTILATION

CPR with Advanced Airway 8 ndash 10 breathsminute

Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

A simultaneous choreographed approach Much more emphasis on the team approach and a realistic

recognition of what and how PARAMEDICS do their job

Recognition that resuscitation is not a ldquolinierrdquo process (Step A THEN Step B etc) but a simultaneous series of actions

ldquohellipin a highly specialized environment such as a critical care unit of a hospital many of the individual components of CPR (compression-ventilation-defibrillation) may be managed simultaneously This approach requires choreography among many highly-trained rescuers who work as an integrated team

In the pre-hospital setting the order of the CPR components performed by the healthcare provider may switch between a sequenced and choreographed model depending on the proficiency of the provider and the availability of resourcesrdquo

- Circulation 2010122[suppl 3]S676 ndashS684

ldquo It is reasonable for healthcare providers to tailor the sequence of rescue actions to the most likely cause of arrestrdquo

THIS MEANS NO MORE COOK-BOOK MEDICINE

New CPR Guidelines

Traditional Healthcare Version

2005 to 2010 changes

Component of CPR

2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

PULSE CHECK HCP Only HCP only Checking for ldquoDEFNITE pulserdquo

SOME THINGS REMAIN IMPORTANTSOME THINGS REMAIN IMPORTANT

RATERATE

DEPTHDEPTH

RELEASERELEASE

UNINTERRUPTEDUNINTERRUPTED

DECREASED DECREASED VENTILATIONVENTILATION

5 KEY5 KEY ASPECTSASPECTS

OFOF GOODGOOD CPRCPR

Compression Rate (at least 100 Minute)

Rate per minute is NOT a function of ldquospeedrdquo of compressions only but a function of both speed ands minimizing no-flow periods (discussed later) for a total compressionsminute

Compressions rates as high as 130 resulted in favorable outcomes

Compression rates lt87minute saw rapid drop off in ROSC

NEW RECOMMENDATION At LEAST 100minute

Better too fast than too slow

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

76

75

58

42

Compression Rate

Target = ~100min with complete release Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH (At least 2 inches)

Previous studies show that only about 27 of compressions were deep enough (Wik 2005)

0 (none) were too deep NEW GIUDELINES The adult sternum

should be depressed at least 2 inches (5 cm) (Class IIa LOE B) with chest compression and chest recoilrelaxation times approximately equal (Class IIb LOE C)

Compression DEPTH

Target = 38-51 mm with complete release Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Complete RELEASERECOIL (Full)

Complete Recoil essential to reduce intrathoracic pressure between compressions

Reducing recoil improves hemodynamics in arrest and improves Coronary Perfusion Pressure (CPP)

Incomplete chest wall recoil can be reduced during CPR by using electronic recording devices that provide real-time feedback

Niles D Nysaether J Sutton R Nishisaki A Abella BS Arbogast K Maltese MR Berg RA Helfaer M Nadkarni V Leaning is common during in-hospital

pediatric CPR and decreased with automated corrective feedback Resuscitation 200980553ndash557

Intra-thoracic Pressure and CPR

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and Recoil

Abella et al 2005 Circulation

INTURRUPTIONS

Pausing for procedures intubation IV pulse check etc)

Pausing for rhythm analysis Pausing after shock to await post-

shock rhythm Pausing to charge clear and shock Unaware of importance of CPR in

ldquobig picturerdquo

No-Flow Ratio (Interruption of CPR)

Target = less than 20 Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

KEY POINT

ldquohellipHigh-quality CPR is important not only at the onset but throughout the course of resuscitation Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPRrdquo

AHA 2010 Guidelines

DECREASING VENTILATION

CPR with Advanced Airway 8 ndash 10 breathsminute

Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

New CPR Guidelines

Traditional Healthcare Version

2005 to 2010 changes

Component of CPR

2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

PULSE CHECK HCP Only HCP only Checking for ldquoDEFNITE pulserdquo

SOME THINGS REMAIN IMPORTANTSOME THINGS REMAIN IMPORTANT

RATERATE

DEPTHDEPTH

RELEASERELEASE

UNINTERRUPTEDUNINTERRUPTED

DECREASED DECREASED VENTILATIONVENTILATION

5 KEY5 KEY ASPECTSASPECTS

OFOF GOODGOOD CPRCPR

Compression Rate (at least 100 Minute)

Rate per minute is NOT a function of ldquospeedrdquo of compressions only but a function of both speed ands minimizing no-flow periods (discussed later) for a total compressionsminute

Compressions rates as high as 130 resulted in favorable outcomes

Compression rates lt87minute saw rapid drop off in ROSC

NEW RECOMMENDATION At LEAST 100minute

Better too fast than too slow

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

76

75

58

42

Compression Rate

Target = ~100min with complete release Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH (At least 2 inches)

Previous studies show that only about 27 of compressions were deep enough (Wik 2005)

0 (none) were too deep NEW GIUDELINES The adult sternum

should be depressed at least 2 inches (5 cm) (Class IIa LOE B) with chest compression and chest recoilrelaxation times approximately equal (Class IIb LOE C)

Compression DEPTH

Target = 38-51 mm with complete release Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Complete RELEASERECOIL (Full)

Complete Recoil essential to reduce intrathoracic pressure between compressions

Reducing recoil improves hemodynamics in arrest and improves Coronary Perfusion Pressure (CPP)

Incomplete chest wall recoil can be reduced during CPR by using electronic recording devices that provide real-time feedback

Niles D Nysaether J Sutton R Nishisaki A Abella BS Arbogast K Maltese MR Berg RA Helfaer M Nadkarni V Leaning is common during in-hospital

pediatric CPR and decreased with automated corrective feedback Resuscitation 200980553ndash557

Intra-thoracic Pressure and CPR

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and Recoil

Abella et al 2005 Circulation

INTURRUPTIONS

Pausing for procedures intubation IV pulse check etc)

Pausing for rhythm analysis Pausing after shock to await post-

shock rhythm Pausing to charge clear and shock Unaware of importance of CPR in

ldquobig picturerdquo

No-Flow Ratio (Interruption of CPR)

Target = less than 20 Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

KEY POINT

ldquohellipHigh-quality CPR is important not only at the onset but throughout the course of resuscitation Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPRrdquo

AHA 2010 Guidelines

DECREASING VENTILATION

CPR with Advanced Airway 8 ndash 10 breathsminute

Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Traditional Healthcare Version

2005 to 2010 changes

Component of CPR

2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

PULSE CHECK HCP Only HCP only Checking for ldquoDEFNITE pulserdquo

SOME THINGS REMAIN IMPORTANTSOME THINGS REMAIN IMPORTANT

RATERATE

DEPTHDEPTH

RELEASERELEASE

UNINTERRUPTEDUNINTERRUPTED

DECREASED DECREASED VENTILATIONVENTILATION

5 KEY5 KEY ASPECTSASPECTS

OFOF GOODGOOD CPRCPR

Compression Rate (at least 100 Minute)

Rate per minute is NOT a function of ldquospeedrdquo of compressions only but a function of both speed ands minimizing no-flow periods (discussed later) for a total compressionsminute

Compressions rates as high as 130 resulted in favorable outcomes

Compression rates lt87minute saw rapid drop off in ROSC

NEW RECOMMENDATION At LEAST 100minute

Better too fast than too slow

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

76

75

58

42

Compression Rate

Target = ~100min with complete release Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH (At least 2 inches)

Previous studies show that only about 27 of compressions were deep enough (Wik 2005)

0 (none) were too deep NEW GIUDELINES The adult sternum

should be depressed at least 2 inches (5 cm) (Class IIa LOE B) with chest compression and chest recoilrelaxation times approximately equal (Class IIb LOE C)

Compression DEPTH

Target = 38-51 mm with complete release Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Complete RELEASERECOIL (Full)

Complete Recoil essential to reduce intrathoracic pressure between compressions

Reducing recoil improves hemodynamics in arrest and improves Coronary Perfusion Pressure (CPP)

Incomplete chest wall recoil can be reduced during CPR by using electronic recording devices that provide real-time feedback

Niles D Nysaether J Sutton R Nishisaki A Abella BS Arbogast K Maltese MR Berg RA Helfaer M Nadkarni V Leaning is common during in-hospital

pediatric CPR and decreased with automated corrective feedback Resuscitation 200980553ndash557

Intra-thoracic Pressure and CPR

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and Recoil

Abella et al 2005 Circulation

INTURRUPTIONS

Pausing for procedures intubation IV pulse check etc)

Pausing for rhythm analysis Pausing after shock to await post-

shock rhythm Pausing to charge clear and shock Unaware of importance of CPR in

ldquobig picturerdquo

No-Flow Ratio (Interruption of CPR)

Target = less than 20 Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

KEY POINT

ldquohellipHigh-quality CPR is important not only at the onset but throughout the course of resuscitation Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPRrdquo

AHA 2010 Guidelines

DECREASING VENTILATION

CPR with Advanced Airway 8 ndash 10 breathsminute

Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

2005 to 2010 changes

Component of CPR

2005 ECC recommendations

2010 ECC Recommendations

DEPTH OF COMPRESSION

1 frac12 - 2 inches Greater than 2 inches

RATE 100 MINUTE At least 100 MIN

VENTILATION 8-10 MINUTE 8-10 MINUTE

CHEST RECOIL 100 100

INTURUPTIONS Minimized Less than 10 seconds goal

PULSE CHECK HCP Only HCP only Checking for ldquoDEFNITE pulserdquo

SOME THINGS REMAIN IMPORTANTSOME THINGS REMAIN IMPORTANT

RATERATE

DEPTHDEPTH

RELEASERELEASE

UNINTERRUPTEDUNINTERRUPTED

DECREASED DECREASED VENTILATIONVENTILATION

5 KEY5 KEY ASPECTSASPECTS

OFOF GOODGOOD CPRCPR

Compression Rate (at least 100 Minute)

Rate per minute is NOT a function of ldquospeedrdquo of compressions only but a function of both speed ands minimizing no-flow periods (discussed later) for a total compressionsminute

Compressions rates as high as 130 resulted in favorable outcomes

Compression rates lt87minute saw rapid drop off in ROSC

NEW RECOMMENDATION At LEAST 100minute

Better too fast than too slow

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

76

75

58

42

Compression Rate

Target = ~100min with complete release Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH (At least 2 inches)

Previous studies show that only about 27 of compressions were deep enough (Wik 2005)

0 (none) were too deep NEW GIUDELINES The adult sternum

should be depressed at least 2 inches (5 cm) (Class IIa LOE B) with chest compression and chest recoilrelaxation times approximately equal (Class IIb LOE C)

Compression DEPTH

Target = 38-51 mm with complete release Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Complete RELEASERECOIL (Full)

Complete Recoil essential to reduce intrathoracic pressure between compressions

Reducing recoil improves hemodynamics in arrest and improves Coronary Perfusion Pressure (CPP)

Incomplete chest wall recoil can be reduced during CPR by using electronic recording devices that provide real-time feedback

Niles D Nysaether J Sutton R Nishisaki A Abella BS Arbogast K Maltese MR Berg RA Helfaer M Nadkarni V Leaning is common during in-hospital

pediatric CPR and decreased with automated corrective feedback Resuscitation 200980553ndash557

Intra-thoracic Pressure and CPR

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and Recoil

Abella et al 2005 Circulation

INTURRUPTIONS

Pausing for procedures intubation IV pulse check etc)

Pausing for rhythm analysis Pausing after shock to await post-

shock rhythm Pausing to charge clear and shock Unaware of importance of CPR in

ldquobig picturerdquo

No-Flow Ratio (Interruption of CPR)

Target = less than 20 Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

KEY POINT

ldquohellipHigh-quality CPR is important not only at the onset but throughout the course of resuscitation Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPRrdquo

AHA 2010 Guidelines

DECREASING VENTILATION

CPR with Advanced Airway 8 ndash 10 breathsminute

Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

SOME THINGS REMAIN IMPORTANTSOME THINGS REMAIN IMPORTANT

RATERATE

DEPTHDEPTH

RELEASERELEASE

UNINTERRUPTEDUNINTERRUPTED

DECREASED DECREASED VENTILATIONVENTILATION

5 KEY5 KEY ASPECTSASPECTS

OFOF GOODGOOD CPRCPR

Compression Rate (at least 100 Minute)

Rate per minute is NOT a function of ldquospeedrdquo of compressions only but a function of both speed ands minimizing no-flow periods (discussed later) for a total compressionsminute

Compressions rates as high as 130 resulted in favorable outcomes

Compression rates lt87minute saw rapid drop off in ROSC

NEW RECOMMENDATION At LEAST 100minute

Better too fast than too slow

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

76

75

58

42

Compression Rate

Target = ~100min with complete release Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH (At least 2 inches)

Previous studies show that only about 27 of compressions were deep enough (Wik 2005)

0 (none) were too deep NEW GIUDELINES The adult sternum

should be depressed at least 2 inches (5 cm) (Class IIa LOE B) with chest compression and chest recoilrelaxation times approximately equal (Class IIb LOE C)

Compression DEPTH

Target = 38-51 mm with complete release Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Complete RELEASERECOIL (Full)

Complete Recoil essential to reduce intrathoracic pressure between compressions

Reducing recoil improves hemodynamics in arrest and improves Coronary Perfusion Pressure (CPP)

Incomplete chest wall recoil can be reduced during CPR by using electronic recording devices that provide real-time feedback

Niles D Nysaether J Sutton R Nishisaki A Abella BS Arbogast K Maltese MR Berg RA Helfaer M Nadkarni V Leaning is common during in-hospital

pediatric CPR and decreased with automated corrective feedback Resuscitation 200980553ndash557

Intra-thoracic Pressure and CPR

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and Recoil

Abella et al 2005 Circulation

INTURRUPTIONS

Pausing for procedures intubation IV pulse check etc)

Pausing for rhythm analysis Pausing after shock to await post-

shock rhythm Pausing to charge clear and shock Unaware of importance of CPR in

ldquobig picturerdquo

No-Flow Ratio (Interruption of CPR)

Target = less than 20 Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

KEY POINT

ldquohellipHigh-quality CPR is important not only at the onset but throughout the course of resuscitation Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPRrdquo

AHA 2010 Guidelines

DECREASING VENTILATION

CPR with Advanced Airway 8 ndash 10 breathsminute

Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Compression Rate (at least 100 Minute)

Rate per minute is NOT a function of ldquospeedrdquo of compressions only but a function of both speed ands minimizing no-flow periods (discussed later) for a total compressionsminute

Compressions rates as high as 130 resulted in favorable outcomes

Compression rates lt87minute saw rapid drop off in ROSC

NEW RECOMMENDATION At LEAST 100minute

Better too fast than too slow

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

76

75

58

42

Compression Rate

Target = ~100min with complete release Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH (At least 2 inches)

Previous studies show that only about 27 of compressions were deep enough (Wik 2005)

0 (none) were too deep NEW GIUDELINES The adult sternum

should be depressed at least 2 inches (5 cm) (Class IIa LOE B) with chest compression and chest recoilrelaxation times approximately equal (Class IIb LOE C)

Compression DEPTH

Target = 38-51 mm with complete release Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Complete RELEASERECOIL (Full)

Complete Recoil essential to reduce intrathoracic pressure between compressions

Reducing recoil improves hemodynamics in arrest and improves Coronary Perfusion Pressure (CPP)

Incomplete chest wall recoil can be reduced during CPR by using electronic recording devices that provide real-time feedback

Niles D Nysaether J Sutton R Nishisaki A Abella BS Arbogast K Maltese MR Berg RA Helfaer M Nadkarni V Leaning is common during in-hospital

pediatric CPR and decreased with automated corrective feedback Resuscitation 200980553ndash557

Intra-thoracic Pressure and CPR

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and Recoil

Abella et al 2005 Circulation

INTURRUPTIONS

Pausing for procedures intubation IV pulse check etc)

Pausing for rhythm analysis Pausing after shock to await post-

shock rhythm Pausing to charge clear and shock Unaware of importance of CPR in

ldquobig picturerdquo

No-Flow Ratio (Interruption of CPR)

Target = less than 20 Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

KEY POINT

ldquohellipHigh-quality CPR is important not only at the onset but throughout the course of resuscitation Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPRrdquo

AHA 2010 Guidelines

DECREASING VENTILATION

CPR with Advanced Airway 8 ndash 10 breathsminute

Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Compression Ratehellip

Percent segmentswithin 10 cpmof AHA Guidelines

31

369

Abella et al 2005 Circulation

76

75

58

42

Compression Rate

Target = ~100min with complete release Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH (At least 2 inches)

Previous studies show that only about 27 of compressions were deep enough (Wik 2005)

0 (none) were too deep NEW GIUDELINES The adult sternum

should be depressed at least 2 inches (5 cm) (Class IIa LOE B) with chest compression and chest recoilrelaxation times approximately equal (Class IIb LOE C)

Compression DEPTH

Target = 38-51 mm with complete release Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Complete RELEASERECOIL (Full)

Complete Recoil essential to reduce intrathoracic pressure between compressions

Reducing recoil improves hemodynamics in arrest and improves Coronary Perfusion Pressure (CPP)

Incomplete chest wall recoil can be reduced during CPR by using electronic recording devices that provide real-time feedback

Niles D Nysaether J Sutton R Nishisaki A Abella BS Arbogast K Maltese MR Berg RA Helfaer M Nadkarni V Leaning is common during in-hospital

pediatric CPR and decreased with automated corrective feedback Resuscitation 200980553ndash557

Intra-thoracic Pressure and CPR

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and Recoil

Abella et al 2005 Circulation

INTURRUPTIONS

Pausing for procedures intubation IV pulse check etc)

Pausing for rhythm analysis Pausing after shock to await post-

shock rhythm Pausing to charge clear and shock Unaware of importance of CPR in

ldquobig picturerdquo

No-Flow Ratio (Interruption of CPR)

Target = less than 20 Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

KEY POINT

ldquohellipHigh-quality CPR is important not only at the onset but throughout the course of resuscitation Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPRrdquo

AHA 2010 Guidelines

DECREASING VENTILATION

CPR with Advanced Airway 8 ndash 10 breathsminute

Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Compression Rate

Target = ~100min with complete release Reality = 60min due to ldquoNo Flow Ratiordquo

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Compression DEPTH (At least 2 inches)

Previous studies show that only about 27 of compressions were deep enough (Wik 2005)

0 (none) were too deep NEW GIUDELINES The adult sternum

should be depressed at least 2 inches (5 cm) (Class IIa LOE B) with chest compression and chest recoilrelaxation times approximately equal (Class IIb LOE C)

Compression DEPTH

Target = 38-51 mm with complete release Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Complete RELEASERECOIL (Full)

Complete Recoil essential to reduce intrathoracic pressure between compressions

Reducing recoil improves hemodynamics in arrest and improves Coronary Perfusion Pressure (CPP)

Incomplete chest wall recoil can be reduced during CPR by using electronic recording devices that provide real-time feedback

Niles D Nysaether J Sutton R Nishisaki A Abella BS Arbogast K Maltese MR Berg RA Helfaer M Nadkarni V Leaning is common during in-hospital

pediatric CPR and decreased with automated corrective feedback Resuscitation 200980553ndash557

Intra-thoracic Pressure and CPR

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and Recoil

Abella et al 2005 Circulation

INTURRUPTIONS

Pausing for procedures intubation IV pulse check etc)

Pausing for rhythm analysis Pausing after shock to await post-

shock rhythm Pausing to charge clear and shock Unaware of importance of CPR in

ldquobig picturerdquo

No-Flow Ratio (Interruption of CPR)

Target = less than 20 Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

KEY POINT

ldquohellipHigh-quality CPR is important not only at the onset but throughout the course of resuscitation Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPRrdquo

AHA 2010 Guidelines

DECREASING VENTILATION

CPR with Advanced Airway 8 ndash 10 breathsminute

Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Compression DEPTH (At least 2 inches)

Previous studies show that only about 27 of compressions were deep enough (Wik 2005)

0 (none) were too deep NEW GIUDELINES The adult sternum

should be depressed at least 2 inches (5 cm) (Class IIa LOE B) with chest compression and chest recoilrelaxation times approximately equal (Class IIb LOE C)

Compression DEPTH

Target = 38-51 mm with complete release Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Complete RELEASERECOIL (Full)

Complete Recoil essential to reduce intrathoracic pressure between compressions

Reducing recoil improves hemodynamics in arrest and improves Coronary Perfusion Pressure (CPP)

Incomplete chest wall recoil can be reduced during CPR by using electronic recording devices that provide real-time feedback

Niles D Nysaether J Sutton R Nishisaki A Abella BS Arbogast K Maltese MR Berg RA Helfaer M Nadkarni V Leaning is common during in-hospital

pediatric CPR and decreased with automated corrective feedback Resuscitation 200980553ndash557

Intra-thoracic Pressure and CPR

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and Recoil

Abella et al 2005 Circulation

INTURRUPTIONS

Pausing for procedures intubation IV pulse check etc)

Pausing for rhythm analysis Pausing after shock to await post-

shock rhythm Pausing to charge clear and shock Unaware of importance of CPR in

ldquobig picturerdquo

No-Flow Ratio (Interruption of CPR)

Target = less than 20 Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

KEY POINT

ldquohellipHigh-quality CPR is important not only at the onset but throughout the course of resuscitation Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPRrdquo

AHA 2010 Guidelines

DECREASING VENTILATION

CPR with Advanced Airway 8 ndash 10 breathsminute

Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Compression DEPTH

Target = 38-51 mm with complete release Reality = only 27 achieve target

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

Complete RELEASERECOIL (Full)

Complete Recoil essential to reduce intrathoracic pressure between compressions

Reducing recoil improves hemodynamics in arrest and improves Coronary Perfusion Pressure (CPP)

Incomplete chest wall recoil can be reduced during CPR by using electronic recording devices that provide real-time feedback

Niles D Nysaether J Sutton R Nishisaki A Abella BS Arbogast K Maltese MR Berg RA Helfaer M Nadkarni V Leaning is common during in-hospital

pediatric CPR and decreased with automated corrective feedback Resuscitation 200980553ndash557

Intra-thoracic Pressure and CPR

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and Recoil

Abella et al 2005 Circulation

INTURRUPTIONS

Pausing for procedures intubation IV pulse check etc)

Pausing for rhythm analysis Pausing after shock to await post-

shock rhythm Pausing to charge clear and shock Unaware of importance of CPR in

ldquobig picturerdquo

No-Flow Ratio (Interruption of CPR)

Target = less than 20 Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

KEY POINT

ldquohellipHigh-quality CPR is important not only at the onset but throughout the course of resuscitation Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPRrdquo

AHA 2010 Guidelines

DECREASING VENTILATION

CPR with Advanced Airway 8 ndash 10 breathsminute

Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Complete RELEASERECOIL (Full)

Complete Recoil essential to reduce intrathoracic pressure between compressions

Reducing recoil improves hemodynamics in arrest and improves Coronary Perfusion Pressure (CPP)

Incomplete chest wall recoil can be reduced during CPR by using electronic recording devices that provide real-time feedback

Niles D Nysaether J Sutton R Nishisaki A Abella BS Arbogast K Maltese MR Berg RA Helfaer M Nadkarni V Leaning is common during in-hospital

pediatric CPR and decreased with automated corrective feedback Resuscitation 200980553ndash557

Intra-thoracic Pressure and CPR

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and Recoil

Abella et al 2005 Circulation

INTURRUPTIONS

Pausing for procedures intubation IV pulse check etc)

Pausing for rhythm analysis Pausing after shock to await post-

shock rhythm Pausing to charge clear and shock Unaware of importance of CPR in

ldquobig picturerdquo

No-Flow Ratio (Interruption of CPR)

Target = less than 20 Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

KEY POINT

ldquohellipHigh-quality CPR is important not only at the onset but throughout the course of resuscitation Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPRrdquo

AHA 2010 Guidelines

DECREASING VENTILATION

CPR with Advanced Airway 8 ndash 10 breathsminute

Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Intra-thoracic Pressure and CPR

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and Recoil

Abella et al 2005 Circulation

INTURRUPTIONS

Pausing for procedures intubation IV pulse check etc)

Pausing for rhythm analysis Pausing after shock to await post-

shock rhythm Pausing to charge clear and shock Unaware of importance of CPR in

ldquobig picturerdquo

No-Flow Ratio (Interruption of CPR)

Target = less than 20 Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

KEY POINT

ldquohellipHigh-quality CPR is important not only at the onset but throughout the course of resuscitation Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPRrdquo

AHA 2010 Guidelines

DECREASING VENTILATION

CPR with Advanced Airway 8 ndash 10 breathsminute

Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Importance of complete recoil

Get EVERY Compression Right

Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and Recoil

Abella et al 2005 Circulation

INTURRUPTIONS

Pausing for procedures intubation IV pulse check etc)

Pausing for rhythm analysis Pausing after shock to await post-

shock rhythm Pausing to charge clear and shock Unaware of importance of CPR in

ldquobig picturerdquo

No-Flow Ratio (Interruption of CPR)

Target = less than 20 Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

KEY POINT

ldquohellipHigh-quality CPR is important not only at the onset but throughout the course of resuscitation Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPRrdquo

AHA 2010 Guidelines

DECREASING VENTILATION

CPR with Advanced Airway 8 ndash 10 breathsminute

Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Get EVERY Compression Right

Critical pressure for Critical pressure for ROSCROSC(Paradis et al JAMA(Paradis et al JAMA19902633257-8)19902633257-8)

Abella et al 2005 Circulation

Cerebral Perfusion Pressures and Recoil

Abella et al 2005 Circulation

INTURRUPTIONS

Pausing for procedures intubation IV pulse check etc)

Pausing for rhythm analysis Pausing after shock to await post-

shock rhythm Pausing to charge clear and shock Unaware of importance of CPR in

ldquobig picturerdquo

No-Flow Ratio (Interruption of CPR)

Target = less than 20 Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

KEY POINT

ldquohellipHigh-quality CPR is important not only at the onset but throughout the course of resuscitation Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPRrdquo

AHA 2010 Guidelines

DECREASING VENTILATION

CPR with Advanced Airway 8 ndash 10 breathsminute

Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Cerebral Perfusion Pressures and Recoil

Abella et al 2005 Circulation

INTURRUPTIONS

Pausing for procedures intubation IV pulse check etc)

Pausing for rhythm analysis Pausing after shock to await post-

shock rhythm Pausing to charge clear and shock Unaware of importance of CPR in

ldquobig picturerdquo

No-Flow Ratio (Interruption of CPR)

Target = less than 20 Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

KEY POINT

ldquohellipHigh-quality CPR is important not only at the onset but throughout the course of resuscitation Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPRrdquo

AHA 2010 Guidelines

DECREASING VENTILATION

CPR with Advanced Airway 8 ndash 10 breathsminute

Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

INTURRUPTIONS

Pausing for procedures intubation IV pulse check etc)

Pausing for rhythm analysis Pausing after shock to await post-

shock rhythm Pausing to charge clear and shock Unaware of importance of CPR in

ldquobig picturerdquo

No-Flow Ratio (Interruption of CPR)

Target = less than 20 Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

KEY POINT

ldquohellipHigh-quality CPR is important not only at the onset but throughout the course of resuscitation Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPRrdquo

AHA 2010 Guidelines

DECREASING VENTILATION

CPR with Advanced Airway 8 ndash 10 breathsminute

Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

No-Flow Ratio (Interruption of CPR)

Target = less than 20 Reality = 48

Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac ArrestWik et al JAMA 2005

KEY POINT

ldquohellipHigh-quality CPR is important not only at the onset but throughout the course of resuscitation Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPRrdquo

AHA 2010 Guidelines

DECREASING VENTILATION

CPR with Advanced Airway 8 ndash 10 breathsminute

Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

KEY POINT

ldquohellipHigh-quality CPR is important not only at the onset but throughout the course of resuscitation Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPRrdquo

AHA 2010 Guidelines

DECREASING VENTILATION

CPR with Advanced Airway 8 ndash 10 breathsminute

Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

DECREASING VENTILATION

CPR with Advanced Airway 8 ndash 10 breathsminute

Post-resuscitation 10 ndash 12min

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Compression-Ventilation Ratio

Ventilation rate = 12min Compression rate = 78min Large amplitude waves = ventilations Small amplitude waves = compressions Each strip records 16 seconds of time

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Reality Suckshellip

Compression Ventilation Ratio 21 47-48 Breaths a minute

47 Nails in a coffin

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Prolonged Ventilations

1048707Ventilation Duration = 436 seconds breath 1048707Ventilation Rate = 11 breaths minute 1048707 time under Positive Pressure = 80

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Everyone sucks

Milwaukee Mean Ventilation Rate

37minute AFTER 2 months training 22minute

Dallas 30minute

Tuscan 34minute

Chicago gt30minute

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Effect of Vent Rate on CPP

12 RR minute

CPP 234 plusmn 10mmHg

MIP 71 plusmn 07 mmHgmin

20 RR minute

CPP 195 plusmn 18 mmHgMIP 116 plusmn 07 mmHgmin

30 RR minute

CPP 169 plusmn 18 mmHgMIP 175 plusmn 10 mmHgmin

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

CPR Prompts

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

CPR FeedbackCPR FEEDBACKCPR FEEDBACK

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

CPR Feed Back

Several studies have demonstrated improvement in chest compression rate depth chest recoil ventilation rate and indicators of blood flow such as end-tidal CO2 (PETCO2) when real-time feedback or prompt devices are used to guide CPR performance

However there are no studies to date that demonstrate a significant improvement in patient survival related to the use of CPR feedback devices during actual cardiac arrest events

Other CPR feedback devices with accelerometers may overestimate compression depth when compressions are performed on a soft surface such as a mattress because the depth of sternal movement may be partly due to movement of the mattress rather than anterior-posterior (AP) compression of the chest

Nevertheless real-time CPR prompting and feedback technology such as visual and auditory prompting devices can improve the quality of CPR (Class IIa LOE B)

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

CPR Marathon

Howard Snitzer 59 survived 96 minutes of CPR with no neuro Deficits

httpabcnewsgocomHealth96-minute-cpr-marathon-saves-minnesota-mans-lifestoryid=13048099

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

CPR Gadgets Gizmorsquos and Ideas

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Interposed Abdominal Compression-CPR (IAC-CPR)

Conventional chest compressions combined with alternating abdominal compressions to improve aortic pressure and thus CPP

Mixed Results in in-hospital studies but overall positive Limited Out of Hospital Studies

No Adult complications but 1 report of traumatic pancreatitis in a pediatric patient

IAC-CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available (Class IIb LOE B)

There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Active Compression-Decompression CPR (ACD-CPR)

Small studies showed improvement but a Cochrane Meta- review of over 1000 patients did not

ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb LOE B)

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Impedance Threshold Device (ITD)

Used both with ETT Face Mask and other advanced Airways

The ITD limits air entry into the lungs

during the decompression phase of CPR creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR

Major reviews have shown some survival to hospital improvement but this may be multi-factorial

The ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb LOE B)

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Mechanical Piston Devices LUCAS THUMPER ETC In 3 Studies the use of a mechanical

piston device for CPR improved end-tidal CO2 and mean arterial pressure during adult cardiac arrest resuscitation

No long term benefit over manual CPR discovered (yet)

There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest

Use of such devices during specific cercumstances when manual CPR is difficult may be done (Class IIb LOE C)

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Load-Distributing Band CPR or Vest CPR (LDB-CPR)

Auto-Pulse is the most common Initial repots were very positive

however a large study showed poor neurological outcomes

Further studies pending The LDB may be considered for use

by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb LOE B)

However there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

ELECTRICAL THERAPIES

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Electrical Therapies Overview

For every minute that passes between collapse and defibrillation survival rates from witnessed VF SCA decrease 7 to 10 if no CPR is provided

When bystander CPR is provided the decrease in survival rates is more gradual and averages 3 to 4 per minute from collapse to defibrillation

CPR prolongs VF delays the onset of asystole and extends the window of time during which defibrillation can occur

Basic CPR alone however is unlikely to terminate VF and restore a perfusing rhythm (exception Lightning strikes)

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

CPR and AED EQUALLY IMPRORTANT

Delays to either the start of CPR or the start of defibrillation reduce survival from SCA

In the 1990s some predicted that CPR could be rendered obsolete by the widespread development of community AED programs

However Cobb (MD for SeattleKing County Medic One System) noted that as more of Seattlersquos first responders were equipped with AEDs survival rates from SCA unexpectedly fell

This decline was attributed to reduced emphasis on CPR and there is growing evidence to support this view

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

TWO MAJOR QUESTIONS

CPR First or Defib First Number of shocks to be delivered in

a sequence before the rescuer resumes CPR (this was also evaluated in 2005)

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

CPR or Defib First

In un-witnessed arrest or arrest 4-5 minutes (or longer) without good sustained CPR a 1 frac12 to 3 minute cycle of high quality CPR may improve the chance of ROSC Survival to discharge and 1 year survival

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

CPR IMPROVING DEFIB

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Effects of ldquoProgressrdquohellip

19781975

1980s and 1990rsquos

King CountySeattle Medic One EMS System Data Cobb 1999

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

CPR FIRST

ROSC

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

CPR FIRST BEFORE DEFIB The rate of survival improved (24 percent

to 30 percent) when CPR was initiated prior to external defibrillation especially in patients with delayed initial response intervals (longer than 4 minutes) 27 percent with CPR versus 17 percent without CPR first

The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 improved from 17 percent to 23 percentpercent

Cobb LA et al Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular

fibrillationJAMA 1999 Apr 7 281 1182-1188

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

CPR First

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation

There is insufficient evidence to determine if 1 1frasl2 to 3 minutes of CPR should ALWAYS be provided prior to defibrillation

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide a cycle of CPR while preparing for defibrillation of patients found by EMS personnel to be in VF

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

CPR First

The exact role of CPR first is unclear but may be implemented by medical director (Class IIb LOE B)

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Reducing Time to Shock

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Reducing Time to Shock

Scene Management CPR during ldquochargingrdquo

Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I LOE B)

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

1 shock vs 3 shocks (stacked)

20o5 ECC recommended a single shock sequence

2 new studies have confirmed this recommendation Biphasic 1st shock success comparable to 3

stacked monophasic shock success Subsequent shocks in a stacked shock

sequence have a very low incremental benefit especially when compared to the benefit of good and sustained CPR

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Updated Energy Recommendations

Monophasic (of anyone still has them) use the MAX possible dose for all shocks Monophasic AEDs can still use old settings

In the absence of biphasic defibrillators monophasic defibrillators are acceptable (Class IIb LOE B)

BiPhasic shocks should follow manufacturers recommendations (Class I LOE B) When this is not known Defib at the maximal

dose is acceptable (Class IIb LOE C)

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Multi-phasic Defibrilators

Data from animal studies suggest that multiphasic waveforms (triphasic quadriphasic or higher) may defibrillate at lower energies and induce less postshock myocardial dysfunction

Human trials are pending ldquoCurrentrdquo based Defib

also under exploration

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

PEDIATRIC Defib

Discussed in more detail later In pediatric defibrillation there are limited data regarding the lowest

effective dose or the upper limit for safe defibrillation

Initial monophasic doses of 2 Jkg are effective in terminating 18 to 50 of VF and 48 of VF using similar doses of biphasic energy

However even with higher energies (up to 9Jkg) defibrillation has been successful with no clear adverse effects

Thus for pediatric patients it is acceptable to use an initial dose of 2 to 4 Jkg (Class IIa LOE C) but for ease of teaching an initial dose of 2 Jkg may be considered

For refractory VF it is reasonable to increase the dose to 4 Jkg

Subsequent energy levels should be at least 4 Jkg and higher energy levels may be considered not to exceed 10 Jkg or the adult maximum dose (Class IIb LOE C)

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

CPR integration after Defibrillation

Similar to 2005 recommendations there is no pulse check after defib

Immediate CPR should be performed even if an organized rhythm is seen (Class I LOE B)

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Defib and an ICD

Allow 30 ndash 60 seconds after an ICD shock prior to a manualAED shock

AP placement of pads prefered but AL placement acceptable Place pads at least 8 cm away from ICDPacer

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

In Hospital AED programs

Limited evidence but consensus supports this approach especially in low acuity and unmonitored wards

In Hospital AED programs have resulted in a lower collapse to shock interval

Goal is less than 3 minutes to shock from collapse

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

VT and TdP To Sync or not to Sync

VT (wPulse) Treat as SVT SYNC TdP (wPulse) treat as VT WO pulse

DEFIB VT and TDP WO Pulse DEFIB

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

PACING

No Longer Recommended for ROUTINE use in Asystole and PEA (Class III LOE B) This is due to ldquomay interrupt CPRrdquo

PACING still Ok for Refractory Bradycardia and 3rd AVBrsquos

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

AIRWAY

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Cric Pressure (Really)

Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation

However it also may impede ventilation and interfere with placement of a supraglottic airway or intubation

If cricoid pressure is used in special circumstances during cardiac arrest the pressure should be adjusted relaxed or released if it impedes ventilation or advanced airway placement

The routine use of cricoid pressure in cardiac arrest is not recommended (Class III LOE C)

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

FiO2 (During Arrest)

Use of 100 inspired oxygen (FIO210) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa LOE C)

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

FiO2 (post arrest)

Increasing Data that hyper-oxia may increase incidence of poor neurological outcomes and increased pulmonary injury

Exact FiO2 recommendations have not been determined

In the post arrest phase if equipment is available titration of FiO2 to SPO2 04 is recommended (Class I LOE C)

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Passive O2 delivery during arrest

Passive O2 delivary via ETT (Boussignac tube or standard ETT) as well as via NRB has been reviewed

In theory because ventilation requirements are lower than normal during cardiac arrest oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway

The studies involved resulted in improved outcomes but it is unsure what role (if any) passive O2 had

At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

ETT

There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest

Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions intubation frequently is associated with interruption of compressions for many seconds EMS Should be doing all first attempts DURING CPR

Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

ETT Continued

In a registry study of 25006 in-hospital cardiac arrests earlier time to invasive airway (5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival

In an urban out-of-hospital setting intubation that was achieved in 12 minutes was associated with better survival than intubation achieved in 13 minutes

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

ETT (MORE GOOD NEWS)

In out-of-hospital urban and rural settings patients intubated during resuscitation had a better survival rate than patients who were not intubated whereas in an in-hospital setting patients who required intubation during CPR had a worse survival rate

Jennings PA Cameron P Walker T Bernard S Smith K Out-of-hospitalcardiac arrest in Victoria rural and urban outcomes Med J Aust 2006185135ndash139

Dumot JA Burval DJ Sprung J Waters JH Mraovic B Karafa MT Mascha EJ Bourke DL Outcome of adult cardiopulmonary resuscitations at a tertiary referral center including results of ldquolimitedrdquo resuscitations Arch Intern Med 20011611751ndash1758

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

ETT (Moral of story)

There are two pitfalls of ETT placement 1- Interruption of CPR 2- Poor Placement practices

Therefore Place during CPR if possible and optimize first attempt (bougie etc)

If you CANT do this then use a supraglottic airway If you cant o this perhaps you should not be a

paramedic Hmmmmmmhelliphellip

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

ETT

The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway

If advanced airway placement will interrupt chest compressions providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb LOE C)

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Securing the Tube

Commercial Device (Class I LOE C) C-Collar andor LSB (Class IIb LOE

C)

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Monitoring of ETT

Continuous Waveform PETCO2 (Class I LOE A)

Colormetric or Non-Waveform PETCO2 (Class IIa LOE b) when Cont waveform is not available HOWEVER not superior to auscultation and visualization

EDD (Class IIa LOE B) for initial but not continuous monitoring

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

ACLS

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

ACLS ndash BIG CHANGE

ldquohellipvascular access drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillationrdquo

ldquo There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest In most cases the timing and sequence of these secondary interventions will depend on the number of providers participating in the resuscitation and their skill levels Timing and sequence will also be affected by whether vascular access has been established or an advanced airway placed before cardiac arrestrdquo

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

ACLS- Vasopressors

EPI Higher doses may be indicated to treat specific problems such as a -blocker or calcium channel blocker overdose (Class IIb LOE A)

1 dose of vasopressin 40 units IVIO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest (Class IIb LOE A)

There are no alternative vasopressors (norepinephrine phenylephrine) with proven survival benefit compared with epinephrine in arrest

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

ACLS- Vasopressors in arrest

The peak effect of an intravenous (IV)intraosseous (IO) vasopressor given as a bolus dose during CPR is delayed for at least 1 to 2 minutes Therefore the exact timing to give vasopressors has not been determined

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

ACLS- Vasopressors in arrest

Potentially if a vasopressor is given with ROSC care could be compromised

Pausing for rhythm checks during the 2 min cycle is not recommended but monitoring of PETCO2 is

If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg) it is reasonable to consider that this is an indicator of ROSC (Class IIa LOE B)

Vasopressors may be deferred until next rhythm check

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

ACLS- Anti-arrhythmics

Amiodarone (Class IIb LOE A) remains a primary recommendation

Lidocaine (Class IIb LOE B) as a secondary due to lack of research

Procainimide may be more effective in terminating VF than lidocaine but dosage regimen is cumbersome

Mag Sulfate only for TdP (Class IIb LOE B)

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

ACLS- Atropine

Atropine gone for AystolePEA ldquoThere is no evidence that atropine has

detrimental effects during bradycardic or asystolic cardiac arrestrdquo

ldquohellipAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb LOE B) For this reason atropine has been removed from the cardiac arrest algorithmrdquo

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

ACLS- BiCarb

In some special resuscitation situations such as preexisting metabolic acidosis hyperkalemia or tricyclic antidepressant overdose bicarbonate can be beneficial

However routine use of sodium bicarbonate is not recommended for patients in cardiac arrest (Class III LOE B) What Defines ROUTINE Does prolonged down time count

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

ACLS- Vascular Access

Several human and animal studies indicate that delay of drugs may effect ROSC These were multi-factorial and small

That said vascular access should be a priority as long as it does not interrupt CPR

It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa LOE C) THIS DOES NOT MANDATE IO PLACEMENT INSTEAD

OF IV Central Venous Access (Class IIb LOE C) for the

appropriately trained provider Peak drug concentrations are higher and drug

circulation times shorter

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

ACLS- Precordial Thump is BAAACK

Precordial thump was associated with ROSC when administered promptly to patients with responder-witnessed asystolic arrest in one study (huh) and Pulseless VTVF in another Not likely to be effective but should do ldquono apparent

harmrdquo The precordial thump may be considered for

termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use (Class IIb LOE B) but should not delay CPR and shock delivery

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

ACLS- EARLY PCI FOR MI ARRESTS

TdP Hx of MI SS prior to arrest recurrentrefractory VTVF

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

BradyCardias

Atropine remains (Class IIa LOE B)THEN Pacing

High AVB (Class IIb LOE C) Refractory to atropine (Class IIa LOE C)

Dopamine Not aldquoNew Doserdquo to TYPO BEGIN 2-10 mcgkgmin then Titrate

Epi Drips 2-10 mcgmin

Iisoproterenol 2-10 mcgmin

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

TachyCardias

Adenocard ndash No change Procainimide ndash No Change Ca Channel Blockers

Diltizem or Verapamil K channel blockers

Sotalol 100 mg (or 15 mgkg) (Class IIb LOE B) can be considered

May be more effective than Lidocaine Lidocaine is ldquoless effectiverdquo in stable VT

than Procainimide Amiodarone or Sotalol Still an option (Class IIb LOE B)

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Tachycardiarsquos A-Fib

Beta -blockers and nondihydropyridine calcium channel blockers such as diltiazem are the drugs of choice for acute rate control in most individuals with atrial fibrillation and rapid ventricular response (Class IIa LOE A)

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

POST ARREST CARE

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Drugs

Note Epi Dose Dopamine Dose Milrinone

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Vasoactive Drugs

More emphasis on crystaloid fluids as well

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Therapeutic Hypothermia

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

Questions

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks

ldquoldquoIt is up to us to save the worldrdquoIt is up to us to save the worldrdquo- Peter Safar- Peter Safar

• Special Thanks