acls 2015 overview - ems coned · 2015-10-29 · o...
TRANSCRIPT
Advanced Cardiac Life Support Guidelines Overview
2015 This overview is a summary of the Guidelines for CPR and ECC and is not meant to replace the textbooks or other supplemental material. It is meant to be used as a study adjunct
Prepared by Judy Haluka
Section One -‐ ADVANCED CARDIAC LIFE SUPPORT OVERVIEW LEARNING OBJECTIVES: The student will have an understanding of the general guidelines for resuscitation as updated October 2015. Many of the treatment guidelines for Advanced Cardiac Life Support (ACLS) are unchanged from 2010. Those that have significant changes in content or application have been highlighted in RED. Changes in the Way Science is Reviewed and Released Rather than five year updates the Guidelines have been posted in a Web Based Format and will be updated continuously. This will help to ensure that new science that may impact mortality and morbidity reach patient care professionals more rapidly. GOALS OF THE AMERICAN HEART ASSOCIATION
• Double bystander CPR rates by 2020 • Double cardiac arrest survival rates by 2020
Ethics:
• Goal is Neuro Intact Discharge not ROSC • Respect for the individuals ability to make their own medical decisions • Withholding and withdrawing care during resuscitation are equivocal • Withholding resuscitation is acceptable if;
o The safety of the rescuers is in question o Obvious signs of death are present o There is a valid advanced directive from the patient
• Use of ECPR (ECMO, Fem – Fem) is acceptable for a short time in patients who have a condition that is fixable in a relative short amount of time
• Multiple variables should be used to decide to stop resuscitation. o PETCO Less than 10 in the intubated patient is a poor prognostic
indicator for surivival • The phase “limitations of care” has been replaced with “limitations of
interventions.” • Prognostication should not occur until after at east 72 hours in the post
arrest patient. o Could be even longer in patients who were sedated or paralyzed.
• All patients who have achieved ROSC and then progressed to death or brain death should be considered for organ donation.
• Patients who have not achieved ROSC may also be considered for donation
o Grafts of patients who did not achieve ROSC did as well at 30 days, 1 year and 5 years as those from patients who had been resuscitation. This includes livers and kidneys.
BASIC LIFE SUPPORT
• Compressions and basic life support remain the key to survival in both in hospital and out of hospital cardiac arrest
• Untrained Lay Persons should be directed by the dispatcher to perform Hands only CPR
o There was no difference in outcome between CPR with ventilations and CPR without ventilations
• Trained rescuers should continue to provide ventilation to all patients • Pediatric patients most often have hypoxic arrests – therefore hands only
CPR is not recommended o If the rescuer is unable or unwilling to perform ventilations
compression only CPR may be used but is not recommended if at all possible
• Coronary Perfusion Pressure is an important component of successful defibrillation. (the amount of blood feeding the heart muscle) This occurs during diastole and so is a function of the full recoil of the chest compression
• Healthcare providers should assess level of consciousness, normal breathing and presence of a pulse simultaneously as part of an organized team
• Compression rate was changed to between 100-‐120 • Ratio remains at 30 compressions to 2 ventilations • Ventilation rate for the intubated patient is changed to 1 breath every 6
seconds (10 breaths per minute) • Compression depth remains at 2 inches for adults and children. 1/3 of the
chest wall depth for infants. A maximum compression depth of 2.4 inches or 6cm. Deeper compressions were associated with non life threatening injury
• The most common error was compressions that were to shallow • Press hard, press fast with complete chest recoil • Rescuers should continue to switch every two minutes avoiding rescuer
fatigue which has been shown to result in incomplete chest recoil • The defibrillator should be utilized immediately when it arrives • Compressors should be continued up until the defibrillator is charged and
ready to shock. • Compressions should be started IMMEDIATELY after defibrillation without
pause for pulse check or rhythm check. They should be continued for two minutes before a pulse check or rhythm check is performed
• Compressions devices are not recommended except in situations where it is dangerous or difficult to do manual compressions, such as in moving ambulances or angiography suites.
• Waveform capnography is recommended o Validate tube placement
o PETCO less than 10 with CPR in progress indicates either poor compressions or poor prognosis
o Return of Spontaneous Respirations (ROSC) will result in an increase in PETCO to 40
o No need to interrupt compressions for pulse checks TWO DIFFERENT CHAINS OF SURVIVAL OUT OF HOSPITAL CHAIN OF SURVIVAL
1. Recognition and activation of the emergency response system 2. Immediate high quality CPR 3. Rapid Defibrillation 4. Basic and Advanced emergency medical services 5. Advanced Life Support post arrest care
IN HOSPITAL CHAIN OF SURVIVAL
1. Surveillance and prevention 2. Recognition and activation of the emergency response system 3. Immediate high quality CPR 4. Rapid defibrillation 5. Advanced life support post arrest care
DEFIBRILATION
• Efficacy drops 7-‐10% for each minute that defibrillation is delayed • Goal in hospital is defibrillation within 5 minutes • Out of hospital goal is to increase public access defibrillation programs that
have been proven to improve survival from out of hospital cardiac arrest (OHCA)
• Defibrillator (or AED) should be used immediately when it becomes available • Manufacturer’s guidelines should be used for first defibrillation level • Each defibrillation should be followed by immediate compressions without
pause for pulse or rhythm check. • Each subsequent defibrillations the energy level should be increased • If using an AED and the only available pads are adult, they can be placed on
infants • Acceptable pad positions: Lateral-‐Lateral, Anterior-‐Lateral, Anterior –
Posterior • Combi pads provide for faster defibrillation (after the first pad placement)
then the use of paddles PLACEMENT OF AEDS IN HOSPITALS
• Increase the number of people able to defibrillate • Decrease the need for arrhythmia recognition in low risk areas • Decrease the amount of time to defibrillation • Recommendation: AED provides for defibrillation times under 3 minutes
• Competing with casinos for survival rates AIRWAY MANAGEMENT
• Healthcare providers should always provide ventilation • Advanced airway (intubation) should be delayed to ROSC (depending upon
level of provider) • If the patient is intubated the ventilations should be delivered 10 times a
minute (1 every 6 seconds) • Use of 100% oxygen during resuscitation is acceptable. Following ROSC
oxygen should be decreased to maintain a saturation between 94-‐99% • The use of ITD devices is not acceptable • The routine use of passive ventilation is not recommended, although can be
acceptable in EMS systems that are delivering “bundled CPR” with groups of high performance CPR and Defib with a tiered response system.
• Narcan has been added to the protocol for patients who are found to have abnormal or inadequate breathing but continue to have a pulse. It has been added for both healthcare providers and basic life support providers.
OXYGEN THERAPY
• Target oxygen saturation is 94-‐99%. The routine administration of oxygen if the saturation is normal is not recommended
• If patient is short of breath =oxygen • COPD = goal oxygen saturation is >90% in the absence of shortness of breath
PRINCIPLES OF CARDIAC ARREST MANAGEMENT
• Medications, advanced airway management and other advanced techniques have no impact on survival to discharge
• Basic Life Support remains the foundation of cardiac arrest survival both in and out of the hospital
• Science shows that patients treated at cardiac arrest centers, teaching hospitals have higher survival rates. Recommendation to establish comprehensive cardiac arrest centers and that post arrest patients be triaged there.
• The post cardiac arrest phase of care is being emphasized. Treatment post arrest has a large impact on neuro intact survival.
PRINCIPLES OF MEDICATION
• Peripheral line is the preferred method of administration if a central line is not already in place
o EMS regularly utilizes intraosseous (IO) as first vascular access in cardiac arrest
o IO is also acceptable as first line access in hospital, but is not used as frequently.
EPINEPHRINE
• While still being utilized at standard doses (1mg every 3-‐5 minutes) a caution has been added. Epinephrine increases the ischemic load of the heart muscle. It has been associated with ROSC but not with an increase in survival to discharge
• May increase coronary perfusion pressure during CPR VASOPRESSIN
• Removed from use during cardiac arrest • No advantage over the use of Epinephrine
AMIODARONE
• Only antiarrhythmic that increased survival to admission. No drug had a proven effect on survival to discharge.
• Does not decrease left ventricular function • 300mg (5mg/kg) IV bolus for refractory ventricular fibrillation or non
perfusing ventricular tachycardia LIDOCAINE
• No longer indicated in the treatment of cardiac arrest in the adult patient unless it is the only drug available
• Science does not support the routine use of Lidocaine in the post arrest patient.
SEARCHING FOR THE CAUSE – if the cause of arrest cannot be discovered and fixed, it is difficult to achieve lasting return of spontaneous circulation. The following are the most common causes of cardiac arrest. They are referred to as the H’s and T’s of cardiac arrest.
1. Hypoxia 2. Hypovolemia 3. Hydrogen ion (Acidosis) 4. Hypo-‐hyperkalemia 5. Hypothermia
T’s are:
1. Toxins (overdoses, medication errors, exposures) 2. Tamponade (cardiac) 3. Tension Pneumothorax 4. Thrombosis (coronary) 5. Thrombosis (pulmonary)
THE NOT RECOMMENDED
• Sodium Bicarbonate during arrest (only after ROSC, governed by blood gases)
• Pacing during arrest • Precordial thump outside the hospital environment
ARRHYTHMIAS In the acute care setting of cardiac failure, the diagnosis of rhythm is de-‐emphasized. The type of arrhythmia is less important that the resulting heart rate. The equation that determines blood pressure and hemodynamic stability is CARDIAC OUTPUT = HEART RATE X STROKE VOLUME. Therefore the treatment of heart rate, whether too slow or too fast is central to adequate resuscitation.
• Not all arrhythmias need to be fixed. • Treated only if causing a problem • Things go wrong when we rush to unnecessary intervention
BRADYCARDIA – heart rate less than 60
• Treat only if symptomatic • Atropine 0.5mg to a total dose of 3mg • Transcutanous Pacing • Dopamine 2-‐10 mcgms/kg/min titrated to heart rate and blood pressure • Epinephrine 2-‐10 mcgms per minute titrated to heart rate and blood
pressure (use with extreme caution if ischemia is suspected) TACHYCARDIA – most tachycardias with a rate less than 150 are compensatory for something else. Be careful not to remove the patient’s compensatory mechanism by slowing the heart rate. STABLE – NARROW COMPLEX TACHYCARDIA
• Attempt vagal maneuvers • Adenosine 6mg followed by 12mg if unsuccessful
o If the rhythm converts, the diagnosis of SVT can be confidently made • Beta Blocker or Calcium Channel Blocker (pick one only) • Consider expert consultation • Remember the goal is not to convert the rhythm, but to control the heart rate
UNSTABLE – NARROW OR WIDE COMPLEX TACHYCARDIA – the risk of stroke is high with cardioversion without prior anticoagulation. The patient must be unstable to make this risk acceptable. Hypotension, unmanageable chest pain, shortness of breath and hemodynamic instability may all indicate the need for emergent cardioversion. STABLE – WIDE COMPLEX TACHYCARDIA
• Adenosine 6mg followed by 12mg if unsuccessful
o If conversion occurs this was SVT not Ventricular Tachycardia (VT does not respond to Adenosine)
• Procainamide 20-‐50mg/min until suppressed or side effect • Amiodarone 150mg over 10 minutes (repeat as needed0
o Prefer consultation with Cardiology first if possible o Be aware of extremely long half life (28 days in healthy adult, 60 days
in patients with depressed renal function) • Sotalol IV 100mg (1.5mg/kg) over 5 minutes
o Avoid if Prolonged QT
POST ARREST CARE • Consider direct transport to or transfer to a comprehensive post cardiac
arrest facility (tertiary teaching hospital) who have higher neuro intact discharge rates
• All patients who are comatose following arrest should have induced hypothermia (32-‐34 Degrees centigrade) for 12-‐24 hours
• Recommend against the use of induced hypothermia using cooled IV fluids in the prehospital setting
• 12 Lead ECG as soon as possible following ROSC to define STEMI cause • All post arrest patients with suspected ischemic cause should be taken to the
cardiac catheterization laboratory emergently. It is reasonable to take all post arrest patients to the lab emergently. Early reperfusion is important to long term survival and maintenance of left ventricular function post arrest.
• Avoid hypotension less than 90mmHg systolic or a mean arterial pressure of 65. Treat hypotension aggressively.
• Fever should be actively avoided following cardiac arrest, particularly in patients who have been rewarmed following induced hypothermia.
• EEGs for diagnosis and treatment of seizures in comatose patients should be performed early and repeated often. Seizures should be treated aggressively.
• Patients who have been resuscitated with 100% oxygen (recommended for adults in cardiac arrest) the Fio2 should be reduced to the lowest level that will maintain an oxygen saturation above 94% in the post arrest period.
• All patients who are resuscitation who ultimately progress to death or brain death should be considered potential organ donors.
• Patients who do not have ROSC can be considered for liver and kidney donations. These grafted organs do equally well in recipients long term.
ACUTE CORONARY SYNDROMES (ACS) includes Non ST Elevation MI (NSTEMI), ST Elevation MI (STEMI and unstable angina. How well the patient will do long term is directly related to how much heart muscle is lost during the acute event. This is a function of the amount of time that the coronary vessel remains closed. For this reason, early recognition of ACS is of paramount importance. Patients at high risk of delayed recognition and treatment include:
PREHOSPITAL
• Older age • Racial and ethnic minorities • Female gender • Lower socioeconomic status • Solitary living arrangements
IN HOSPITAL
• Non-‐classical presentation • Confounding diagnostic issues • Provider misinterpretation
EARLY 12 LEAD ECGs
• Proven to decrease the amount of time to vessel opening upon arrival at the hospital
• Computer assisted interpretation is not recommended because of high incidence of false negatives
• If the ECG cannot be transmitted, studies have shown that the interpretation of trained non physician health care providers is accurate and should be used to activate the cardiac catheterization laboratory prior to patient’s arrival
• Transmission of the ECG to the Emergency Department MD is the preferred method of interpretation
ACUTE TREATMENT -‐ ACS
• Continuous monitoring for arrhythmias • Oxygen therapy if short of breath or if oxygen saturation is less than 94%
(90% in COPD) • Nitroglycerin
o Hold if RV Infarction with inferior wall MI o Move V4 to V4R – if 1mm ST elevation hold Nitroglycerin
• Pain Control o Goal is zero (Pain is associated with ischemia and increased risk of life
threatening arrhtyhmias) o Caution if using Morphine in the treatment of Unstable Angina
ACUTE MYOCARDIAL INFARCTION – STEMI – the goal of treatment is the earliest possible reperfusion of the vessel. Door to balloon time should be 90 minutes. The ultimate goal is opening the vessel within 120 minutes of symptoms onset.
• Biomarkers alone cannot be used to risk stratify ACS patients. High sensitivity Troponin at presentation and then at 3 and 6 hours in conjunction with Low Risk Stratification such as TIMI score should be used to predict less than 1% chance of MACE at 30 days.
• Plavix 300mg – It would be reasonable to consider administration in the prehospital setting for patients being triaged for direct PCI.
• When possible STEMI patients should be transported directly to centers capable of percutaneous coronary intervention 24/7 (PCI)
• There is no clear evidence to support the administration of Heparin by EMS • Aspirin 325mg • Beta Blockade in the first 12 hours • Heparin should be administered for 48 hours • Consider the use of Glycoprotein IIb/IIIa Inhibitors • ACE Inhibitor prior to Discharge • Statin prior to discharge
REPERFUSION RECOMMENDATIONS
• PCI is the preferred and lowest risk intervention for acute MI. However there are situations in which fibrinolysis may be considered.
• The combined treatment of finbrinolysis followed by immediate PCI is not recommended.
• Fibrinolysis may be considered when o Patient presents within 2 hours of system onset and delay to PCI is
>60 minutes o Patient presents within 2-‐3 hours of onset and delay to PCI is >60-‐120
minutes (may be reasonable) o Patient presents within 3-‐12 hours of onset and delay to PCI is up to
120 minutes (may be considered) • Fibrinolysis becomes considerable less effective after 6 hours and so delayed
PCI may actually be preferred if it is not possible immediately. • In patients presenting to the ED of a non PCI capable hospital, the
recommendation is immediate transfer to PCI facility rather than the administration of fibrinolysis.
ACUTE CORONARY SYNDROME (ACS) NSTEMI – ST Depression or Dynamic T wave Inversion
• Aspirin 325mg • Nitroglycerin (if not contraindicated) • Heparin (for at least 48 hours) • Consider PO Beta Blockade • Consider Plavix • Consider Glycoprotein IIb/IIIa Inhibitor
STROKE RECOGNITION AND TREATMENT RECOGNITION
• Utilization of Cincinnati Prehospital Stroke Scale (72% accuracy) o Facial Droop
o Arm Drift o Speech o Obtain ONSET OF SYMPTOM TIME
TREATMENT
• EMS – direct triage to Comprehensive Stroke Treatment Centers • Non Contrast CT within 10 minutes of arrival in the Emergency Department • rtPA within 3 hours of onset of symptoms acceptable for all patients • rtPA within 4.5 hours of onset of symptoms acceptable for most patients • Interventional Radiology for patients beyond acceptable time frames or with
special presentations or comorbidities
BIBLIOGRAPHY
Atkins DL, Berger S, Duff JP, Gonzales, JC, Hunt EA, Joyner BL, Meaney PA, Niles, DE, Samson RA, Schexnayder SM. Part II: pediatric basic life support and cardiopulmonary resuscitation quality: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency cardiovascular Care. Circulation. 2015;132(suppl 2): S519-‐S525. (Circulation. 2015;132(suppl 2):S519-‐S525. DOI: 10.1161/CIR000000000000000265.) © 2015 American Heart Association, Inc. Kleinman ME, Brennan EE, Goldberger ZD, Swor RA, Terry M. Bobrow BJ, Gazmuri RJ, Travers AH, Rea T. Part 5: adult basic life support and cardiopulmonary resuscitation quality: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(suppl 2): S414-‐S435. (Circulation. 2015,132(suppl 2) S414-‐S435. DOI: 10.1161/CIR00000000000259.) © American Heart Association, Inc. Neumar, RW Shuster M, Callaway CW, Gent LM, Atkns D, Bhanji F, Brooks SC, deCaen AR, Donmino MW, Ferrer JME, Kleinman ME, Kronick SL, Lavonas EJ, Link MS, Mancini ME, Morrison LJ, o’Connor RE, Sampson RA, Schexnayder SM, Singletary EM, Sinz EH, Travers AH, Wyckoff MH, Hazinski MF. Part 1: executive summasry: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(suppl 2):S3150S367. (Circulation.2015;132)suppl2):S315-‐S367.DOI: 10.1161/CIR.00000000000000000252.) Mancini ME, Diekerma /ds/ Hoadley TA. Hoadley TA Kadlec KD, Leveille MH, McGowan JE, Munkwitz MM, Panchal AR, Sayre MR, Sinz EH. Part 3: ethical issues: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(suppl 2):S383-‐S396. (Circulation.2015;132(suppl 2):S383-‐S396.DOI: 10.11161/CIR.0000000000000000000254)
Brooks SC, Anderson ML, Bruder E daya MR, Gaffney A, Otto CW, Singer aj, Thiagarajan RR, Travers AH. Part 6: alternative techniques and ancillary devices for cardiopulmonary resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(suppl 2):S436-‐S443. Circulation.2015;132(suppl 2):S383-‐S396.DOI: 10.11161/CIR.0000000000000000000260) Link MS, Berkow LC, Kudenchuk PJ, Halperin HR, Hess EP, Moitra VK, Neumar RW, O’Neil BJ, Paxton JH, Silvers SM, White RD, Yannopoulos D, Donnino MW. Part 7: adult advanced life support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(suppl 2):S444-‐S464. Circulation.2015;132(suppl 2):S383-‐S396.DOI: 10.11161/CIR.0000000000000000000261) Lavonas EJ, Drennan JR, Gabrielli A, Heffner AC, Hoyte CO, Orkin AM, Sawyer KN, Domminino MW. Part 10: special circumstances of resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(suppl 2):S-‐S501-‐S518. Circulation.2015;132(suppl 2):S383-‐S396.DOI: 10.11161/CIR.0000000000000000000264) Callaway, CW, Donnino MW, Fink EL, Gieocadin RG, Golan E, Kern KB, Leary M, meurer WJ, peberdy MA, thompson TM, Zimmerman JL. Part 8: post cardiac arrest care: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(suppl 2):S465-‐S482. Circulation.2015;132(suppl 2):S383-‐S396.DOI: 10.11161/CIR.0000000000000000000262) O’Connor RE, Al Ali AS, Brady WJ, Ghaemmaghami CA, Menon V, Welsford M, Shuster M. Part 9: acute coronary syndromes: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(suppl 2):S483-‐S500. Circulation.2015;132(suppl 2):S383-‐S396.DOI: 10.11161/CIR.0000000000000000000263.)
SECTION TWO – BASCIC CARDIAC LIFE SUPPORT (BCLS) LEARNING OBJECTIVES: After completing this section, the student will be able to demonstrate knowledge of Basic Life Support topics including the BLS Survey, compressions, airway management, and defibrillation consistent with the American Heart Association 2015 Guideline Update. BASIC LIFE SUPPORT Out of hospital cardiac arrest (OHCA) occurs 326,000 times a year. That’s about 132 people for every 100,000. CPR and Early defibrillation provides the best chance of survival from this catastrophic event. CPR and early defibrillation can almost double the chance of long term survival from cardiac arrest. Unfortunately only 10% to 65% of OHCA victims actually receive CPR from bystanders prior to the arrival of Emergency Medical Services (EMS). This results in very low survival rates in OHCA. There are a number of guideline updates that are aimed at increasing these numbers. The goal of the American Heart Association (AHA) is to double bystander CPR numbers by the year 2020. The following recommendations are designed to help achieve that goal.
• Early dispatcher recognition of cardiac arrest o All EMS dispatchers should ascertain the presence or absence of
normal breathing immediately after obtaining the location of the emergency.
o If normal breathing is absent, cardiac arrest should be assumed and instructions for hands only CPR provided to the rescuer
• Lay persons are being taught to utilize a cell phone to call 911. Immediately after dialing the phone should be put on speaker and placed next to the patient.
o Allows for the rescuer to begin compressions sooner and to follow the dispatcher’s instruction.
• Social Media o The development of programs allowing dispatchers to notify nearby
potential rescuers via social media have been tested successfully in several markets. Their development is being encouraged.
• Only 20% of cardiac arrests occur in public. The balance occur in private residences. Those not occurring in public have a greater chance of CPR in progress than those occurring in residence.
o This can be approved by dispatchers providing early instruction for hands only CPR to 911 callers.
CHAINS OF SURVIVAL – recognizing the different needs of EMS vs Hospitals in the response to cardiac arrest, two different chains of survival have been developed. IN HOSPITAL CARDIAC ARREST (IHCA)
1. Surveillance and prevention 2. Recognition and activation of the emergency response system 3. Immediate high quality CPR 4. Rapid defibrillation 5. Advanced life support and post arrest care
OUT OF HOSPITAL CARDIAC ARREST (OHCA)
1. Recognition and activation of the emergency response system 2. Immediate high quality CPR 3. Rapid defibrillation 4. Basic and advanced emergency medical services 5. Advanced life support and post arrest care
LAY RESCUER CPR DELIVERY
• Scene safety is always evaluated first. The most important person at the scene is YOU!
• The patient is evaluated for response. If unresponsive, a cell phone should be utilized to call 911. Immediately place the cell phone on speaker and set in next to the patient so that you can continue with CPR immediately.
• Assess the patient for NORMAL breathing. o Remember that some patients may have gasping (agonal) breaths.
These are not considered normal and do not mean that compressions should be delayed
• The patient should be supine on a hard surface such as the floor or if in a bed something hard should be placed under the upper portion of the body in order for the compressions to be effective.
• Immediately upon determination that the patient is not breathing normally, the hands are placed on the bottom 1/3 of the sternum (just below the center of the breast bone) and compressions started
• Compressions are performed by pushing hard and fast on the breast bone at a rate of 100-‐120 per minute.
• The depth of compressions in the adult should be 2” to 2.4” (5-‐6cm) o The most common error is not pushing hard enough
• Compressions should be continued until either the AED is ready for defibrillation or EMS arrives and takes over the rescue.
• Interruptions of CPR for any reason should be minimized. The maximum interruption for any reason is 10 seconds.
• If another rescuer is present they should be rotated every two minutes
o This prevents rescuer fatigue that can result in limiting chest recoil which is very important to survival.
• If the rescuer is trained and able, ventilations should be delivered at a ratio of 30 compressions to 2 ventilations
o Chest rise should be used as the evaluation tool to define successful ventilation
SCIENCE BEHIND THE GUIDLEINES Coronary Perfusion Pressure – is the amount of blood that is being delivered down the coronary arteries to feed the heart muscle itself. Coronary Perfusion Pressure (CPP) is the most important factor in successful defibrillation and survival. It is diastolic and therefore falls to zero very quickly following arrest and is built over several seconds of compressions. It is a function of not the down stroke of compressions but of the recoil of the chest wall. This is because the coronary arteries as well as the ventricles fill during the diastolic phase. This is the reason that continuous compressions started as soon as possible following arrest have the largest impact on survival. Compression fraction of at least 60% is the goal. This means that compressions should be done AT LEAST 60% of the time of arrest to achieve the designed rate of compressions (100-‐120/min) This can be compared to a factory worker who is capable of making 100 widgets per hour. However, if he takes a ten minute break the result will be only 90 widgets in an hour. Therefore the rate of compressions is dependent upon not only the speed of compressions, but also the number of interruptions. This is referred to as compression fraction. HANDS ONLY vs CPR WITH VENTILATIONS In the environment of the lay rescuer there was no difference in survival when the lay rescuer performed hands only CPR or when ventilations were added. Therefore dispatchers are taught to provide instructions to lay rescuers for Hands Only CPR. The trained rescuer in the out of hospital environment may add ventilations to the sequence. DEFIBRILLATION
• Public access defibrillation (PAD) programs that have made Automated External Defibrillators (AED) available for use by the public
• The defibrillator should be used as soon as it becomes available • Cornerstone of therapy for ventricular fibrillation (VF) and ventricular
tachycardia (VT)
• Compressions should be continued until the instant before the shock is delivered.
HEALTHCARE PROVIDER DELIVERY OF CPR (BCLS)
• Survival from IHCA is substantially lower on weekends and nights when compared to weekday daylight shifts.
• Low income and African American patients also have a lower IHCA survival rate
• Most of the IHCA are the result of deterioration from other things such as respiratory issues. MET or RRT should be utilized aggressively on medical/surgical wards to prevent deterioration of sick patients to cardiac arrest.
Compressions
• Assessment of IHCA can occur simultaneous as a team effort. Level of
consciousness, presence of absence of normal breathing as well as the presence or absence of a pulse can be assess all at the same time rather than in a predetermined order.
• In order for compressions to be effective, the patient should be placed on a CPR compliant surface or a spine board or CPR board should be placed under their upper body. Keep in mind that most procedural tables such as those in cardiac cath labs or GI labs are CPR compliant. Gurneys used to transport patients from department to department are also CPR compliant in most cases.
• Compressions should be started immediately with emphasis on limiting interruptions. The longest interruption should be 10 seconds or less for any reason. The goals should be a compression fraction of at least 60%.
• Compressions are delivered at a rate of 100-‐120 per minute. • Compression depth should be between 2 and 2.4 inches (5-‐6cm) Although
non life threatening injuries have been reported with compression depth greater than 2.4 inches, the most common error is compressions that are too shallow.
• Infants and children compression depth is 1/3 of the depth of the anterior posterior chest wall.
• Because coronary perfusion pressure (CPP) is dependent upon diastolic pressure, the recoil of the chest wall following each compression is especially important. For this reason the compression should be changed every two minutes in order to avoid rescuer fatigue. Fatigued rescuers tend to lean on the chest wall and not allow complete recoil
• The use of visual and audio feedback devices to measure the efficacy of compressions during CPR is encouraged.
• Manual compressions remain the standard. The use of automated compression devices is not recommended except where doing compressions are unsafe or difficult such in an angiography suite or in a moving ambulance.
VENTILATIONS
• Healthcare providers should always ventilate as well as perform compressions.
• Ventilations in the patient who does not have an advanced airway in place is done using a ratio of 30 compressions to 2 ventilations (30:2)
• If the patient has an advanced airway in place pausing for ventilations is no longer necessary or desirable.
o Ventilations are then performed at a rate of 10 per minute or one ventilation every 6 seconds
• Evaluation of successful ventilation is based upon seeing the patient’s chest rise and fall.
• Hyperventilation should be avoided. Hyperventilation causes increased pressure within the chest decreasing CPP and ventricular filling.
• In the patient with a pulse but absence of normal breathing, the patient should be ventilated 10 times per minute (1 every 6 seconds)
• Mouth to mouth is very efficient. Each breath should be given over a period of 1 second.
• Mouth to Barrier Device – the risk of transmission through mouth to mouth ventilation is very low. It is reasonable to begin resuscitation without a barrier device. When using a barrier device, the rescuer should not delay compressions while setting up the device.
• Bag Valve Mask – provides positive pressure ventilation without an advanced airway; therefore it may produce gastric inflation and its complications.
o Two rescuers should utilize it. The first to seal the mast and the second to compress the bag.
o Not recommended to be used by a single rescuer o Cricoid pressure for relief of gastric insufflation is NOT recommended
• Supragottic Airways o Devices such as the LMA, esophageal tracheal combitube and the King
airway are currently within the scope of practice of BLS in many areas. Ventilations with a bag through these devices provide an acceptable alternative to bag valve mask ventilation
• Endotracheal Intubation – should be delayed until ROSC. Studies have shown that patients intubated early in cardiac arrest had worse outcomes than those who were not intubated. This may be due to interruptions in compressions and skill level of the provider.
o If the provider is skilled in intubation and it can be achieved without interruption in chest compressions it can be considered during cardiac arrest resuscitation.
EARLY DEFIBRILLATION • The AED or manual defibrillator should be utilized immediately upon arrival
at the patient’s side. • Turn the AED on and following the prompts • Compressions should be continued until the last second prior to the shock. • Compressions should be started immediately following shock without a
rhythm or pulse check. o Most patients with ROSC have a decreased cardiac output and
therefore remain severely hypotensive. They will benefit by having cardiac output supplemented by compressions for two minutes
o If the patient does not achieve ROSC then immediate compressions are indicated. To pause to check rhythm or pulse would result in a compression fraction of less than the goal of 60%.
• Use of a manual defibrillator is covered in the defibrillation section of the course
BIBLIOGRAPHY
Berg RA, Hemphill R, Abella BS, Aufderheide TP, Cave DM, Hazinski MF, Lerner EB, Rea TD, Sayre MR, Swor RA. “Part 5: adult basic life support: 2010 American Heart Association Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care”. Circulation. 2010;122(suppl 3):S685-‐S705. http://circ.ahajournals.org/content/122/18_suppl_3/S685 Neumar, RW Shuster M, Callaway CW, Gent LM, Atkns D, Bhanji F, Brooks SC, deCaen AR, Donmino MW, Ferrer JME, Kleinman ME, Kronick SL, Lavonas EJ, Link MS, Mancini ME, Morrison LJ, o’Connor RE, Sampson RA, Schexnayder SM, Singletary EM, Sinz EH, Travers AH, Wyckoff MH, Hazinski MF. Part 1: executive summasry: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(suppl 2):S3150S367. (Circulation.2015;132)suppl2):S315-‐S367.DOI: 10.1161/CIR.00000000000000000252 Brooks SC, Anderson ML, Bruder E daya MR, Gaffney A, Otto CW, Singer aj, Thiagarajan RR, Travers AH. Part 6: alternative techniques and ancillary devices for cardiopulmonary resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(suppl 2):S436-‐S443. Circulation.2015;132(suppl 2):S383-‐S396.DOI: 10.11161/CIR.0000000000000000000260) Kleinman ME, Brennan EE, Goldberger ZD, Swor RA, Terry M. Bobrow BJ, Gazmuri RJ, Travers AH, Rea T. Part 5: adult basic life support and cardiopulmonary resuscitation quality: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation.
2015;132(suppl 2): S414-‐S435. (Circulation. 2015,132(suppl 2) S414-‐S435. DOI: 10.1161/CIR00000000000259.) © American Heart Association, Inc. SECTION THREE – ETHICS IN RESUSCITATION LEARNING OBJECTIVE: After completing this section, the student will be able to demonstrate knowledge of legal and ethical considerations for beginning or discontinuing resuscitation. Medical ethics have always been difficult. They become much more difficult in the environment of cardiac arrest because of the patient’s inability to communicate his/her wishes to the healthcare provider. For this reason, providers must take extra care to attempt to discover the patient’s wishes if expressed prior to cardiac arrest and to follow them whenever possible. The principle of consent applies both to the patient and to those who are called upon to make decisions for them. The following must be components of consent or refusal of consent. The patient and/or surrogate must understand
• Nature of the illness or injury • Risks of treatments or lack of treatment • Benefits of treatment or lack of treatment • Alternatives of any proposed intervention
In addition, the patient and/or surrogate must be able to demonstrate understanding of that information by;
• The patient receives and understands accurate information about their illness/injury. His/Her condition and prognosis are explained n detail, in a language that can be understood readily by the patient. The information should include explaining treatments or interventions and the risks and benefits of each.
• The patient is then able to repeat this information in their own language to demonstrate that they in fact understand the information.
• The patient thinks about the decision and makes a decision that is based on his/her own beliefs or value system. The patient is able to explain their decision.
In cardiac arrest this is not possible from the patient and frequently is not possible by a surrogate decision maker. Where the wishes of the patient are unknown all possible attempts at resuscitation must be made. Once the patient’s wishes become known via family/surrogate they should be acted upon. Not initiating resuscitation if desires are known and discontinuing life support treatment of in hospital cardiac arrest during or after resuscitation are ethically equivalent and clinicians should not hesitate to withdraw support on ethical grounds when functional survival is highly unlikely. There are several ways that a patient can let us know of his/her wishes. Having an advance directive, living will or power of attorney makes it much easier to understand what the patient would want if he/she were competent. Let’s take a look at some of them. Keep in mind that laws regarding many of these tools differ from countries and states/provinces and will continue to change. Living Will – provides evidence of the patient’s wishes if he/she is in a terminal condition and unable to make decisions on their own. In most states it can be enforced as evidence of the patient’s desires. The format can differ greatly. A living will can be very detailed, providing very specific information such as the desire to receive antibiotics but not CPR, or to be hydrated but not fed. They can also be very general in direction and simply say that “life sustaining treatment is not desired if I am considered terminally ill.” It is generally easier if the document outlines specific desires of the patient. Healthcare Advance Directive – legal document that is based on the Patient Self Determination Act of 1990 and is legally binding in the United States. It communicates the thoughts, wishes and preferences for healthcare decisions that might need to be made during periods of incapacity. They can be verbal or written and can be communicated via living wills or conversations. Most courts prefer that an Advance Directive be in writing but will consider verbal information in the absence of a written document. Healthcare Power of Attorney – legal document that gives another person the ability to make medical decisions for the patient if they are deemed incompetent or unable to make decisions. This works best when combined with a Living Will or Advance Directive so that the patient’s surrogate knows what the patient’s wishes are. DO NOT RESUSCITATE or DNR orders must be dated and signed by an ordering physician (or alternative depending on each State’s laws). Many facilities have changed the name of this order to “Allow Natural Death.” Unfortunately, the DNR order has been misinterpreted by many healthcare providers as a Do Not Provide Care order, which has never been the intent. A DNR order simply means to not resuscitate or provide care that would prolong life beyond what would otherwise result in natural death. It does not mean to without pain control, hydration for comfort, medications such as antibiotics, or other routine medical interventions. For
example; a patient with a DNR order who gets pneumonia should still be transported to the hospital, the EMS crew should still start an IV, provide oxygen and transport to the hospital where the patient should receive standing treatment for pneumonia. If during the course of treatment the patient’s heart was to stop or they were to stop breathing, then and only then, does the DNR order have an impact. At that point, CPR would be withheld and the patient would not be intubated. DNR orders are normally not valid outside of a hospital or healthcare facility such as a long-‐term care facility. This can be managed by the EMS provider obtaining a medical command order from an Emergency Department physician. Some US states also have out-‐of-‐hospital DNR bracelets or necklaces that may be worn by patients not wishing to be resuscitated by the EMS crews. Principle of Futility Patients or families may ask for care that is highly unlikely to improve health outcomes. Providers are not obliged to provide such care when there is scientific and social consensus that the treatment is ineffective. If the purpose of a medical treatment cannot be achieved, the treatment can be considered futile. Withholding resuscitation and the discontinuation of life sustaining treatment during or after resuscitation are ethically equivalent. In situations when prognosis is uncertain, a trial of treatment may be initiated while further information is gathered to help determine the likelihood of survival, the patient’s preferences, and the expected clinical course. Withholding and Withdrawing CPR in Out-‐of-‐hospital Cardiac Arrest (OHCA) All trained rescuers should immediately begin CPR without seeking consent, because delay in care dramatically decreases the chances of survival. Withholding CPR may be appropriate in a few situations.
• Attempts to perform CPR would place the rescuer at risk of serious injury or mortal peril
• Obvious clinical signs of irreversible death • A valid, signed, and dated advanced directive indicating that resuscitation is
not desired, or a valid, signed and dated DNAR order
OHCA DNAR Orders The ideal out-‐of-‐hospital DNAR order is portable and can be carried on the person. Delayed or token efforts such as so-‐called “slow codes” (knowingly providing ineffective resuscitation efforts) are inappropriate. It compromises the ethical integrity of healthcare providers, uses deception to create a false impression, and may undermine the provider patient relationship. The practice of pseudo resuscitation was self-‐reported by paramedics to occur in 27% of cardiac arrests. Termination of BLS Efforts
1. Arrest was not witnessed by EMS provider or first responder 2. No return of spontaneous circulation after 3 rounds of AED analysis 3. No AED shocks were delivered
The BLS termination of efforts can reduce the transport of cardiac arrest to 37% without compromising the care of potentially viable patients. The rule should be applied BEFORE moving to the ambulance for transport. Implementation of the rule includes real time contacting of medical control when the rule suggests termination. Criteria for Not Starting CPR
• Few criteria can predict futility of resuscitation • All should have resuscitation attempts unless obvious signs of death • Threat to rescuer safety • Valid DNAR or OOHDNR Order
TERMINATING RESUSCITATION FOLLOWING ALS RESUSCIATION ATTEMPTS No one indicator is prognostic of functional survival. The following can be taken into consideration. No one prognostic indicator should be used to make the decision.
• PETCO <10 despite continued compressions in an intubated patient • Lack of shockable rhythm after 30 minutes of advanced life support • No response after prolonged resuscitation • Inabiity to define reversible cause of cardiac arrest
The following situations suggest benefit in prolonged resuscitation;
• Hypothermia • The presence of a shockable rhythm for a prolonged period of time • Young patient without comorbid conditions • Known cause of cardiac arrest that may be reversible
Prognostication following Cardiac Arrest
• The timing of the decision to terminate life support can be an extremely difficult one and must take multiple things into consideration
• Must not begin sooner than 72 hours after the patient has been returned to normal temperature
• May have to be postponed even longer if the patient has been heavily sedated or paralyzed during the course of their post arrest treatment
• Typically 4.5 – 5 days after return of spontaneous circulation (ROSC) Organ Donation following Cardiac Arrest All patients who have been achieved ROSC and then progress to death or brain death should be considered for organ donation. Even patients who have not achieved ROSC should be considered for liver and kidney donations in facilities capable of immediate removal. Grafts from donors who did not achieve ROSC did
equally well at 30 days, 1 and 5 years as those from donors who achieved ROSC following cardiac arrest. ETHICS QUIZ
1. How many hours must one wait (as a minimum) to begin prognostication of a patient who is post cardiac arrest?
a. 72 hours b. 9 days c. 24 hours d. 16 hours
2. Which of the following is part of informed consent? a. The patient must be less than 70 years old b. The patient must be able to complete a H & P Questionnaire c. Explaining risks, benefits and alternatives to recommended care d. The patient reads the form and signs it
3. A patient in the Emergency Department arrest soon after arriving. The patient was alone one admission. He is an older gentleman who appears to be ill. The healthcare provider should:
a. Assume that the patient would want to be saved and begin resuscitation
b. Because he looks ill, resuscitation should be withheld c. Attempt to find a family member prior to beginning resuscitation d. Begin resuscitation, but use BLS skills only
4. CPR should not be started if a. There are obvious signs of death such as rigor mortis present b. In patients older than 90 c. In patients with terminal illness d. In patients that you don’t think will survive
5. One sign of poor prognosis in cardiac arrest is a. PETCO <10 despite adequate compressions b. The presence of a scar in the middle of the patient’s chest indicating
open heart surgery in his past c. Age greater than 70 years d. Ventricular Fibrillation as an arresting rhythm
QUIZ ANSWERS
1. A 2. C 3. A 4. A 5. A
BIBLIOGRAPHY
Mancini ME, Diekerma /ds/ Hoadley TA. Hoadley TA Kadlec KD, Leveille MH, McGowan JE, Munkwitz MM, Panchal AR, Sayre MR, Sinz EH. Part 3: ethical issues: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(suppl 2):S383-‐S396. (Circulation.2015;132(suppl 2):S383-‐S396.DOI: 10.11161/CIR.0000000000000000000254 Morrison LJ, Klerzek 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. 2010:122(SUPPL 3):S665-‐S675. http://circ.ahajournals.org/content/122/18_3/S665
SECTION FOUR -‐ ELECTRICAL THERAPIES LEARNING OBJECTIVE: After completing this section, the student will be able to determine when defibrillation or cardioversion is indicated. The student will demonstrate understanding of equipment and patient preparation and defibrillation delivery. If chest compressions are the foundation of resuscitation, then defibrillation represents the cornerstone. This section will discuss the importance of early defibrillation, correct paddle and pad placement, dosage and indications. In addition, synchronized cardioversion for the unstable patient will be discussed. On a good day, the heart responds to a single pacemaker, causing depolarization throughout the myocardium and ultimately contraction. The single most common cause of cardiac arrest in the adult patient is ventricular fibrillation. In ventricular fibrillation, there is literally an electrical storm within the heart. Many focuses are attempting to act as the lead pacemaker. The result is the lack or organized contraction and therefore no blood is pumped forward, blood pressure falls to zero and the patient arrests. Defibrillation causes global depolarization allowing the sinus node to once again take over the lead as the pacemaker of the heart. Key determinants of success include, health of the myocardium, coronary perfusion pressure (the amount of blood going down the coronary arteries to feed the heart muscle), and time to defibrillation. An excellent example of how defibrillation works is the comparison of the heart to a classroom. If the instructor gets boring and one or two students get louder or funnier than the instructor, the classroom quickly disintegrates into mayhem. (Ventricular Fibrillation) If the instructor were to pick up a textbook and slam it down on the desk, everyone in the room would shut up allowing the instructor to once again gain control of the classroom. That is what defibrillation does. It “shuts up” all of the ectopic foci allowing the sinus node to once again take over as the pacemaker of the heart.
Shows how to use the defibrillator and different ways to place the paddles with discussion of how to choose.
Watch the video at http://youtu.be/rOfZ_IUpvns
A LOOK AT THE SCIENCE The chance of survival diminishes quickly following ventricular fibrillation arrest. For every minute the patient remains down without intervention, the chance of survival decreases 7-‐10%. If CPR is initiated, oxygen is supplied to the myocardium and the decrease in chance of survival is more gradual, about 3-‐4% per minute. Ventricular fibrillation, left untreated will quickly become asystole. Chest compressions can delay the onset of asystole. If arrest is witnessed and a defibrillator available, defibrillation should be performed immediately. If not, the AED should be utilized immediately when it arrives. In out-‐of-‐hospital cardiac arrest EMS may initiate CPR while checking rhythm and preparing defibrillation that may deliver oxygen and fuel to the myocardium making it more likely to respond to defibrillation. The efficacy of biphasic defibrillation is much higher than that of old monophasic shocks. If using a monophasic defibrillator (which would be unusual) initial shock dose should be 360 joules. The defibrillator manufacturer guidelines should be followed. Guidelines will recommend defibrillation between 150-‐200 joules for first defibrillation. Immediately following defibrillation, compressions should be resumed. There is no pause for pulse check. If the rhythm has failed to convert and the patient remains in ventricular fibrillation, compressions are the most important intervention. If the rhythm has converted and the patient is in a perfusing rhythm it is almost always hypo or not perfusing for some time following conversion. Compressions will help to augment those pressures. There was no evidence that performing compressions in patients with an organized rhythm would stimulate ventricular fibrillation. Interruptions of more than 10 seconds for pulse checks, rhythm checks or change of compressors was associated with poorer survival rates and lower conversion rates for ventricular fibrillation.
• The largest electrode or pad works best. 8-‐12 cm is acceptable. Smaller electrode size may result in myocardial necrosis and therefore be harmful.
• AED programs in Airports, casinos, and first responder programs with police officers have shown survival rates of 41-‐74% from out-‐of-‐hospital witnessed
VF arrest when immediate bystander CPR is provided and defibrillation occurs within about 3-‐5 minutes of collapse.
• 80% of cardiac arrests occur in private residential settings, however survival was not improved in homes of high-‐risk individuals equipped with AEDs, compared to homes where only CPR training was provided.
DEFIBRILLATION WITH IMPLANTED CARDIOVERTER DEFIBRILLATOR If the patient has an ICD that is delivering shocks, wait 30-‐60 seconds to allow the ICD to complete the treatment cycle before attaching the AED. Occasionally, the analysis and shock cycles of automatic ICDs and AEDs will conflict. There is the potential for pacemaker or ICD malfunction after defibrillation when pads are placed near the device. Pacemaker spikes with unipolar pacing may confuse AED software and may prevent VF detection. The anterior-‐posterior and anterior-‐lateral locations are acceptable. It might be reasonable to avoid placing the pads or paddles over the device. In-‐Hospital Use of Automated External Defibrillators Evidence from two retrospective and one historical study indicated higher rates of survival to hospital discharge when AEDs were used to treat adult VF or Pulseless VT in the hospital. Defibrillation may be delayed when arrest occurs in unmonitored hospital beds and in outpatient and diagnostic facilities. AEDs may be considered for the hospital setting as a way to facilitate early defibrillation. The goal of hospital defibrillation is that it should occur within 3 minutes of collapse especially in areas where staff have no rhythm recognition skills or defibrillators are used infrequently. Synchronized Cardioversion
• Timed with the QRS complex to avoid shock delivery during the relative refractory portion of the cardiac cycle when it would most likely produce VF.
• Recommended to treat SVT due to reentry, atrial fibrillation, atrial flutter and atrial tachycardia
• Recommended to treat monomorphic VT with pulses. • Not recommended for junctional tachycardia or multifocal atrial tachycardia
Pacing • Not recommended for patients in asystolic cardiac arrest. • No improvement in the rate of admission to hospital or discharge when
paramedics or physicians attempted to provide pacing in Asystole. • Has a negative effect as it may delay chest compressions.
BIBLIOGRAPHY
Link MS, Atkins DL, Passman RS, Halperin HR, Samson RA, White RD, Cudnik MT, Berg MD, Kudenchuk PJ, Kerber RE. “Part 6: electrical therapies: automated external defibrillators, defibrillation, cardioversion, and pacing: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care”. Circulation. 2010;122(suppl 3):S706–S719. http://circ.ahajournals.org/content/122/18_suppl_3/S706 SECTION FIVE – MANAGEMENT OF RESPIRATORY AND CARDIAC ARREST LEARING OBJECTIVE: After completing this section, the student will be able to demonstrate knowledge of airway adjunctions available in the treatment of respiratory and cardiac arrest. The student will understand the principles of pharmacological intervention during cardiac arrest. The student will demonstrate knowledge of treatment recommendations for Bradycardia, Stable and Unstable Tachycardias of both wide and narrow complex origin. Chest compressions and early defibrillation remains central to successful resuscitation. There are a number of other adjunct therapies that may have significant impact on survival. The following chapter will review the recommendations of the American Heart Association regarding the flow of resuscitation, basic medications that should be administered and a review of the treatment of ventricular fibrillation, bradycardia and tachycardia. SUMMARY
• Continuous waveform capnography should be utilized during resuscitation o Verifies endotracheal tube placement o Verifies ROSC with an increase to 40 o Provides feedback of adequate compressions during arrest
• Vasopressin is no longer indicated in the treatment of cardiac arrest • Epinephrine while being used is used with caution. This is true especially in
suspected ischemic cardiac arrest • Passive oxygenation is no longer recommended except in EMS systems who
deliver bundled CPR in a tiered response system.
• Endotracheal intubation is delayed until ROSC (based upon skill of providers who are present during resuscitation)
• The ventilation rate for the adult patient with an advanced airway in place is 10 per minute
Adjuncts for Airway Control and Ventilation The purpose of ventilation during CPR is to maintain adequate oxygenation and sufficient elimination of carbon dioxide. Because both systemic and pulmonary perfusion are substantially reduced during CPR, normal ventilation perfusion relationships can be maintained with a minute ventilation that is much lower than normal. During CPR with an advanced airway in place a lower rate of rescue breathing is needed to avoid hyperventilation. Once an airway is in place the patient should be ventilated at a rate of 10/min or one breath every six seconds. There is no longer a need to pause compressions for ventilation purposes. Oxygen delivery during CPR is limited by blood flow rather than by arterial oxygen content. During the first few minutes, the lone rescuer should not interrupt compressions for ventilation. Advanced airway placement in cardiac arrest should never delay initial CPR and defibrillation for ventricular fibrillation cardiac arrest. Oxygen during CPR Use of 100% oxygen during cardiac arrest is recommended because it optimizes arterial oxyhemoglobin content and in turn oxygen delivery. Following ROSC the FIO2 should be lowered to the least required to maintain an oxygen saturation above 94%. Passive Oxygen Delivery During CPR The use of passive oxygenation is not recommended. It was not supported by science. The exception is in the out of hospital setting when used by a tiered EMS response system as part of “bundled care.” Bag Valve Mask (BVM) Ventilation BVM is an acceptable method of providing ventilation and oxygenation during CPR but is a challenging skill that requires practice. It is not recommended for the lone provider. When ventilations are performed by a lone rescuer, mouth to mouth, or mouth to mask are more efficient. Two people should utilize the BVM. One seals the mask and maintains an open airway while the second rescuer compresses the bag. Oropharyngeal Airways (OA)
OAs are used routinely in the deeply comatose or arrest patient to maintain an airway that remains unobstructed by the tongue. The airway is measured from the tip of the ear lobe to the corner of the mouth. The result is an airway that is long enough to be placed on top of the tongue in the posterior nasopharynx but not long enough to obstruct the airway opening. It cannot be used in the conscious patient or the patient with a gag reflex as it will induce vomiting and risk of aspiration. The OA is placed by inserting it upside down (with the end facing up) until resistance is met in the back of the mouth. At that time, the airway is rotated into the nasopharynx on top of the tongue. Alternatively, the OA can be inserted anatomically correct (with the end pointed down) using a tongue blade to hold the tongue forward and down until the airway is placed. Nasopharyngeal Airways (NA) NAs are useful in patients with airway obstruction or risk of obstruction by the tongue. They are especially useful in patients with a clenched jaw such as seizures. Care must be taken during insertion as 30% are associated with airway bleeding after placement. The NA should be lubricated. It is inserted gently in the nose in an anatomically correct position and gently pushed forward until the trumpet end is against the nose. If resistance is met while advancing the airway it should be removed and attempted in the other side of the nose. The NA is much less likely to activate the gag reflex or to induce vomiting. ADVANCED AIRWAY All healthcare providers should be trained in delivering effective oxygenation and ventilation with a bag valve mask. ACLS providers should be trained and practice the insertion of some type of advanced airway. ENDOTRACHEAL INTUBATION, although the gold standing for airway management is deferred until ROSC unless a skilled provider is present. Patients who were intubated early in arrest in several studies had worse neurological and survival numbers than those in whom intubation was deferred until ROSC. The timing of intubation is based upon the level and frequency of training and practice of the providers present.
• Intubation is frequently associated with interruption of compressions for many seconds. Decreases in compression fraction are associated with poor outcomes in cardiac arrest.
• Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be accomplished successfully without interrupting compressions. The Combitube and the King airway can be placed by Basic Life Support providers in many areas.
• Providers should have a secondary strategy for airway management if they are unable to utilize their first choice of an advanced airway.
• Continuous waveform capnography should be utilized to confirm placement of an endotracheal tube. It should be used in additional to clinical assessment. Capnography is the most efficient method of monitoring placement of the tube as well as adequate ventilation.
• Once an airway is in place compressions do not have to be paused to deliver ventilations. The patient should be ventilated at a rate of 10/minute or once every 6 seconds.
Supraglottic Airways
• Does not require visualization of the glottis, so both initial training and maintenance of skills are easier. They can be placed by BLS providers in many regions.
• The following airways have been studied in cardiac arrest; laryngeal mask airway (LMA), Combitube and the laryngeal tubing (King Airway).
• Can provide ventilation that is as effective as that provided by a bag valve mask and endotracheal intubation.
• There is no evidence that the use of any advanced airway adjunct increases survival in out of hospital cardiac arrest.
• During CPR, the use of a supraglottic airway is a reasonable alternative to BVM.
COMBITUBE
• Similar advantages to endotracheal tube; isolation of the airway, reduced risk of aspiration and more reliable ventilation than BVM.
• Providers of all levels of experience were able to insert the Combitube and deliver ventilations
• No difference in outcome when compared with intubation KING AIRWAY
• More compact and less complicated to insert. • Inserted blindly without the need for visualization. • In a study of trained paramedics, the tube was inserted successfully 85% of
the time and the patient was ventilated successfully. LARYNGEAL MASK AIRWAY (LMA)
• More secure and reliable than BVM. • Does not ensure absolute protection from aspiration, but less likely than with
BVM
• Successful ventilations during CPR reported in 72-‐97% of patients • Does not require visualization, training is simpler than endotracheal
intubation • Has advantage over endotracheal intubation when access to the patient is
limited by location or position • Acceptable alternative to endotracheal intubation
ENDOTRACHEAL INTUBATION Endotracheal Intubation was once thought to be the only acceptable way to ventilate a patient. However, complications such as trauma, interruptions of compressions and hypoxemia from prolonged attempts have made other airway adjuncts come to the forefront. Frequent experience or retraining is essential for providers who perform intubation. EMS systems that perform intubation should provide a program of ongoing quality improvement to minimize complications. Indications include:
1. Inability of the provider to ventilate the unconscious patient adequately with the BVM and
2. The absence of airway protective reflexes (coma or cardiac arrest) Guidelines:
• Interruptions in chest compressions cannot be more than 10 seconds • Interruptions are not necessary at all when utilizing a supraglottic airway
adjunct • Intubation has been associated with a 6-‐25% incidence of unrecognized tube
misplacement or displacement. This risk increases when the patient has to be moved as in the out of hospital setting. Both clinical and confirmation devices must be used to verify tube placement immediately after insertion and again after the patient is moved.
Confirming Tube Placement
• Clinical Methods o Visualizing bilateral chest rise with ventilation o Bilateral lung sounds
• Waveform Capnography o Should be used anytime a patient has been intubated to both verify
placement and to monitor for displacement o 100% sensitivity and 100% specificity in identifying correct
endotracheal tube placement o Most reliable method of confirming and monitoring placement
• Colormetric C02 detectors can be used when waveform capnography is not available. The accuracy of these devices does not exceed that of auscultation and direct visualization for confirming position in victims in cardiac arrest.
General
• Ventilation is associated with increased intrathoracic pressure and may reduce venous return and cardiac output. This is true especially in patients with COPD or Hypovolemia.
• Slower ventilations are associated with increased survival rates. • The ventilation rate for adults who are apneic is 10/minute or one
ventilation every 6 seconds. Automatic Transport Ventilators
• Can be useful for ventilation of adult patients who are not in cardiac arrest with an advanced airway in place
• During prolonged resuscitation efforts the use of an ATV may allow the EMS team to perform other tasks while providing adequate ventilation and oxygenation.
ADULT CARDIAC ARREST – PRIORITIES OF CARE
• Push hard and fast >2 inches but no more than 2.4 inches (5-‐6cm) at a rate of 100-‐120 per minute
• Compressions should be done for at least 60% of the time during cardiac arrest (Compression Fraction)
• Avoid excessive ventilations (10 per minute) • Rotate compressors every 2 minutes to avoid rescuer fatigue resulting in
restriction of chest coil caused by leaning on the chest wall • If no advanced airway in place 30:2 compression ventilation ratio • Quantitative waveform capnography
o If PETCO <10mmHG compressions are inadequate and need to be addressed
• Intra-‐arterial pressure o If diastolic pressure is less than 20mmHg attempt to improve CPR
quality as coronary perfusion pressure is not adequate SHOCK ENERGY
• Biphasic – manufacturer’s guidelines (120-‐200 joules); if unknown use 200 joules. Second and subsequent shocks should be equivalent or high dose. Many EMS systems leave their monitors set on maximum output. Biphasic defibrillators adjust their output based upon transthoracic resistance calculated via algorithm.
PHARMACOLOGICAL THERAPY
It is important to realize that no medication was associated in any trial with increased survival to discharge. Epinephrine and Amiodarone were associated with increased ROSC and so continue to be utilized in cardiac arrest.
• Epinephrine 1mg every 3-‐5 minutes IV/IO o Caution regarding Epinephrine Although it increases coronary
perfusion pressure it also causes extreme vasoconstriction and increases myocardial oxygen demand and ischemia
• VASSOPRESSIN IS NO LONGER UTIIZED IN CARDIAC ARREST • Amiodarone 300mg repeated in 8-‐10 minutes at 150mg for refractory VF and
Pulseless VT. It is given IV or IO. REVERSBLE CAUSES – early in resuscitation consideration must be given to the cause of arrest. The goal is to find a reversible cause that can be fixed during resuscitation thus increasing the chance of long term neuro intact survival. The most common causes of reversible cardiac arrest are:
• Hypovolemia • Hypoxia • Hydrogen ion (Acidosis) • Hypo or hyperkalemia • Hypothermia • Tension peneumothorax • Tamponade (cardiac) • Toxins (medication errors, overdoses, exposures) • Thrombosis (Pulmonary) • Thrombosis (Coronary)
Survival from cardiac arrest requires both BLS and a system of ACLS with integrated post cardiac arrest care. ACLS interventions other than defibrillation, such as medications and advanced airways, although associated with an increased rate of ROSC have not been shown to increase the rate of survival to hospital discharge. It remains to be seen if improved rates of ROSC may translate into improved survival to discharge with better implementation of good quality CPR techniques. Algorithms have been simplified and redesigned to emphasize the importance of high quality CPR in all cardiac arrest rhythms. Vascular access, drug delivery and advanced airway placement should not cause significant interruptions in chest compressions or delay defibrillation. There is insufficient evidence to recommend a specific timing or sequence of drug administration and advanced airway placement during cardiac arrest. Understanding the importance of diagnosing and treating the underlying cause of cardiac arrest is fundamental to management. In patients with ROSC it is important to begin post cardiac arrest care immediately to avoid re-‐arrest and optimize the patient’s chance of long term survival with good neurologic function.
PHYSIOLOGIC PARAMETERS Cardiac arrest is the most critically ill condition, typically monitored by ECG and pulse checks. Many studies indicate that the monitoring of PETCO2, coronary perfusion pressure, and central venous oxygen saturation provides valuable information on both the patient’s condition and response to therapy. PULSES Providers frequently try to palpate arterial pulses during compressions to assess the effectiveness of compressions. No studies have shown the validity or clinical utility of checking pulses during ongoing CPR. Because there are no valves in the inferior vena cava, retrograde blood flow into the venous system may produce femoral venous pulsations. Palpation of pulses when chest compressions are paused is a reliable indicator of ROSC but is potentially less sensitive then other physiological measurements. PULSE OXIMETRY Typically does not provide a reliable signal because pulsatile blood flow is inadequate in peripheral tissue beds. But the presence of a pleth waveform on pulse oximetry is potentially valuable in detecting ROSC. During CPR it is not a reliable indicator of the severity of tissue hypoxemia, hypercarbia, or tissue acidosis. Therefore routine measurement is not indicated. Access for Medication During Cardiac Arrest Drug administration is of secondary importance. After CPR and attempted defibrillation providers can establish IV or intraosseous (IO) access. IO is most often placed as the primary vascular access in out of hospital cardiac arrest. Access should be obtained without interrupting compressions. There is insufficient evidence to specify exact time parameters or precise sequence with which drugs should be administered. Peripheral drugs should be followed by a 20ml bolus of IV fluid to ensure delivery to the central circulation during cardiac arrest. IO cannulation provides access to a non-‐collapsible venous plexus, enabling drug delivery similar to that achieved by peripheral venous access at comparable doses. Trained providers may consider the placement of a central line. Drug concentrations are higher and drug circulation times are shorter. However, placement many times causes interruptions in compressions negatively affecting outcome. Peripheral lines should be used unless the skill of the provider would permit them to place a central line without the significant interruption of compressions.
Medications EPINEPHRINE produces alpha-‐receptor properties that can increase coronary perfusion pressure and cerebral perfusion pressure during CPR. The value and safety of the beat effects of epinephrine are controversial because they may increase myocardial workload and reduce subendocardial perfusion. A retrospective study of patients with and without Epinephrine found improved ROSC with epinephrine but no difference in long term survival between the treatment groups. Epinephrine should be administered in 1mg doses every 3-‐5mg during resuscitation. This should be done with the consideration and caution of understanding that the ischemic load of the heart muscle may be increased by each administration. VASOPRESSIN has been removed from the treatment algorithm for cardiac arrest. ANTIARRHYTHMICS – there is no evidence that any antiarrhythmic drug given routinely during human cardiac arrest increases survival to discharge from the hospital. Amiodarone may be considered in the treatment of VF and Pulseless VT. Paramedic administration of 300mg of Amiodarone improved hospital admission rates when compared with administration of placebo or 1.5mg/kg of Lidocaine. Additional studies documented improvements in termination of arrhythmias when Amiodarone was given to humans or animals with VF or hemodynamically unstable VT. An initial dose of 300mg can be followed by 1 dose of 150mg. There is limited experience with Amiodarone when given IO. Lidocaine – there is inadequate evidence to recommend the use of Lidocaine in cardiac arrest. It has no proven short or long term effect in cardiac arrest and therefore is not recommended. Magnesium Sulfate – is not recommended in the treatment of patients in cardiac arrest.
INTERVENTIONS NOT RECOMMENDED DURING CARDIAC ARREST ATROPINE – no prospective controlled clinical trials have examined the use of atropine in Asystole or bradycardic PEA cardiac arrest. Available evidence suggests that routine use of atropine during PEA or Asystole is unlikely to have a therapeutic benefit and is not recommended. It has been removed from the cardiac arrest algorithm. SODIUM BICARBONATE – Tissue acidosis and resulting acidemia during cardiac arrest and resuscitation are dynamic processes resulting from no blood flow and low flow during CPR. Rapid ROSC are the mainstays of restoring acid base balance during cardiac arrest. The majority of studies demonstrated no benefit or found a
relationship with poor outcome. Bicarbonate may compromise coronary profusion pressure by reducing systemic vascular resistance. It can create extracellular alkalosis that will shift the oxyhemoglobin saturation curve and inhibit oxygen release. In some special situations such as preexisting metabolic acidosis, hyperkalemia or tricyclic antidepressant overdose, bicarbonate can be beneficial. Routine use of bicarbonate during arrest is not recommended. FIBRINOLYSIS – Two large clinical trials have failed to show any benefit in outcome with fibrinolytic therapy during CPR. One showed an increased risk of intracranial bleeding associated with the routine use. When pulmonary embolism is known to be the cause of arrest fibinolytic therapy can be considered. IV FLUIDS – Normothermic fluid, hypertonic and chilled fluids have been studied in animal and small human studies without a survival benefit. If cardiac arrest is associated with extreme volume loss, such as in hypovolemic PEA, intravascular volume should be promptly restored. However routine fluid boluses should not be administered. PACING – is not effective in cardiac arrest and no studies have observed a survival benefit from pacing. Electrical pacing is not recommended for routine use in cardiac arrest, and is considered possibly harmful (Class III) PRECORDIAL THUMP – is not recommended in the out-‐of-‐hospital setting. May be considered for termination of witnessed monitored unstable ventricular tachycardia when a defibrillator is not immediately ready for use. Bradycardia Bradycardia is defined as a heart rate of less than 60 however when bradycardia is the cause of symptoms, the rate is generally less than 50 and that is the definition used by AHA. Hypoxia is a common cause of bradycardia. Evaluation of the patient with bradycardia should pay particular attention to signs of increased work of breathing and provide supplementary oxygen. The patient should be evaluated for blood pressure and have IV access. If possible a 12-‐lead ECG should be completed to determine the rhythm. VERY IMPORTANT: the provider must identify signs and symptoms of poor perfusion and determine if THOSE SIGNS ARE LIKELY TO BE CAUSED BY THE BRADYCARDIA! If the signs and symptoms are not caused by the bradycardia, then the underlying issue must be found and treated. If the bradycardia is suspected to be the cause of acute altered mental status, ischemic chest discomfort, acute heart failure, hypotension or other signs of shock, the patient should receive immediate treatment.
Atrioventricular (AV) blocks are classified as first, second and third degree. Blocks may be caused by medications or electrolyte disturbances, as well as structural problems resulting from AMI or other myocardial diseases.
• First Degree = prolonged PR interval (>.20) o Usually benign
• 2nd Degree Mobitz Type I o The block is at the AV node o Often transient and asymptomatic
• 2nd Degree Mobitz Type II o The block is usually below the AV node within the Purkinje system o Often symptomatic with the potential to progress to complete AV
block • Third Degree AV Block
o May occur at the AV node, bundle of His or bundle branches o No impulses pass between the atria and ventricles o Can be permanent or transient depending on the underlying cause
Atropine – remains the first line agent for acute symptomatic bradycardia. Studies show that atropine improved heart rate, symptoms and signs associated with bradycardia.
• Reverses cholinergic mediated decreases in heart rate and should be considered a temporary measure while preparing a pacemaker for patients with block at the AV node or sinus arrest
• Dose 0.5 mg IV every 3 – 5 minutes to a total dose of 3 mg • Use cautiously in patients with acute coronary ischemia or MI as increased
heart rate may worsen ischemia or increase infarction size • Not likely to work in patients with Type II or Third Degree heart block. These
are better treated with beta drugs or pacemakers
Transcutaneous Pacer • May be useful in the treatment of symptomatic bradycardia • Study compared Dopamine and TCP, no differences were observed between
treatment groups in survival to hospital discharge • TCP at best is a temporizing measure • Painful in conscious patients • It is reasonable to use in unstable patients in whom atropine has failed
Dopamine • Both alpha and beta • Can be titrated to more selectively target heart rate or vasoconstriction
• May be used for patients with symptomatic bradycardia especially associated with hypotension
Epinephrine • Beta and alpha actions • May be used for patients with bradycardia especially if hypotensive
Adult Tachycardia (with a Pulse) 1. Assess whether the tachycardia is causing the symptoms (rarely the case if
the heart rate is less than 150/min). If the tachycardia is compensatory, i.e., for fever, hypovolemia, congestive heart failure, treat the underlying cause. If the heart rate is lowered in those patients, the patient will decompensate.
2. Maintain patent airway and administer oxygen if the patient is hypoxic. 3. Cardiac monitor, blood pressure and pulse oximetry 4. If the patient is;
o Hypotensive o Acutely altered mental status o Signs of shock o Ischemic chest discomfort o Acute heart failure
(Consider sedation and immediate cardioversion: if narrow complex consider Adenosine)
5. If not unstable evaluate for QRS >0.12 seconds. If yes; o IV access and 12-‐Lead ECG o Consider adenosine only if regular and monomorphic o Consider antiarrhythmic infusion o Consider expert consultation
6. If not unstable and QRS less than 0.12 seconds o IV access and 12 – Lead ECG o Vagal maneuvers o Adenosine (if regular) o Beta Blocker or Calcium Channel Blocker o Consider expert consultation
Note: If the etiology of the rhythm cannot be determined, the rate is regular, and the QRS is monomorphic, recent evidence suggests that IV adenosine is relatively safe for both treatment and diagnosis. However, adenosine should not be given for unstable or for irregular or polymorphic wide complex tachycardia as it may cause deterioration into ventricular fibrillation.
BIBLIOGRAPHY
Neumar RW, Otto CW, Link MS, Kronick SL, Shuster M, Callaway CW, Kudenchuk PJ, Ornato JP, McNally B, Silvers SM, Passman RS, White RD, Hess EP, Tang W, Davis D, Sinz E, Morrison LJ. “Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care”. Circulation. 2010;122(suppl 3):S729–S767. http://circ.ahajournals.org/content/122/18_suppl_3/S729 Neumar, RW Shuster M, Callaway CW, Gent LM, Atkns D, Bhanji F, Brooks SC, deCaen AR, Donmino MW, Ferrer JME, Kleinman ME, Kronick SL, Lavonas EJ, Link MS, Mancini ME, Morrison LJ, o’Connor RE, Sampson RA, Schexnayder SM, Singletary EM, Sinz EH, Travers AH, Wyckoff MH, Hazinski MF. Part 1: executive summasry: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(suppl 2):S3150S367. (Circulation.2015;132)suppl2):S315-‐S367.DOI: 10.1161/CIR.00000000000000000252.) Link MS, Berkow LC, Kudenchuk PJ, Halperin HR, Hess EP, Moitra VK, Neumar RW, O’Neil BJ, Paxton JH, Silvers SM, White RD, Yannopoulos D, Donnino MW. Part 7: adult advanced life support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(suppl 2):S444-‐S464. Circulation.2015;132(suppl 2):S383-‐S396.DOI: 10.11161/CIR.0000000000000000000261)
SECTION SIX – POST CARDIAC ARREST MANAGEMENT The management of a patient following ROSC is a systemic problem. The goal is to maintain blood flow to the brain and vital organs and limiting injury caused by reperfusion. This requires an organized approach to the patient as a whole. If we are to increase the number of patients discharged from the hospital neuro intact we must become experts at the post cardiac arrest phase of care. In order to return the patient to normal function, identification and treatment of the condition causing the cardiac arrest is essential. In addition, identification and treatment of the injuries to multiple organs that occur during cardiac arrest is essential. The care of post arrest patients is as individual as the disease process causing the arrest in the first place. IMMEDIATE 12 LEAD ECG The 12 Lead ECG should be performed immediately upon return of spontaneous circulation. Most adult cardiac arrests are the result of ischemia. Many patients have ST elevation following cardiac arrest. ANGIOGRAPHY All patients with ST elevations following cardiac arrest should be taken emergently to the cardiac catheterization laboratory. 96% of patients with ST elevation were found to have treatable coronary lesions and 58% of patients without ST elevation were found to have treatable coronary lesions. Coronary angiography should be performed emergently for all OHCA who remain comatose or who are hemodynamically stable and fail to demonstrate STEMI. Other potential benefits to taking the patient emergently to the cardiac catheterization laboratory include the ability to place supportive devices such as intraortic balloon pulsation devices (IABP). BLOOD PRESSURE GUIDELINES Blood pressures of less than 90mmHg or greater than 100mmHg were associated with higher morbidity post cardiac arrest. No single method of blood pressure maintenance has proven superior to others. A mean arterial pressure of greater than 80mmHg was associated with lower mortality rates and better neurological outcome at hospital discharge. Therefore, immediately correction blood pressure less than 90mmHg (mean arterial pressure of 65mmHg) is recommended. This can be done using a variety of methods depending upon the patient. These include the use of volume, vasopressor agents and supportive devices.
TARGETED TERMPERATURE MANAGMENET (TTM) – INDUCED HYPOTHERMIA 2015 Guidelines recommend cooling all patients with coma (lack of meaningful response to verbal stimuli) following ventricular fibrillation or pulseless ventricular tachycardia arrest. The patient should be cooled to 32-‐340C and kept there for 12 – 24 hours. Both active and passive rewarming are acceptable. There are no patients that induced hypothermia following cardiac arrest is contraindicated. The recommendations for TTM following IHCA were made stronger. Once the patient has been rewarmed or permitted to return to normal temperature, fever should be treated aggressively. SEIZURES An EEG should be done early in treatment and repeated frequently looking for seizure activity. Seizures in the post cardiac arrest patient should be treated aggressively. The same treatment that is used for other status epilepticus patients is considered acceptable. VENTILATION AND OXYGENATION PaC02 should be maintained in the normal range. Normocarbia (end tidal CO2) of 30-‐40 or PaCO2 of 35-‐45. There may be individual patient issues that dictate the use of different parameters. Post arrest, the highest oxygen concentration available should be used until partial pressure of arterial oxygen can be measured. After measurement is available FIO2 should be titrated to the lowest possible number to maintain an oxygen saturation of greater than 94%. Keep in mind that many patients have vasoconstriction in the immediate post arrest period making measurement using pulse oximetry difficult. Arterial blood gases should be used in this situation. PROGNOSTICATION Prognostication should not begin until at least 72 hours after the post arrest patient has returned to normal temperature. This may be extended by the use of sedation and paralysis in the post arrest period. Typically it is 4-‐4.5 days after ROSC for patients treated with TTM. ORGAN DONATIONS All patients who have ROSC and progress to death or brain death should be considered as organ donors. Those who do not achieve ROSC at centers with ability to recover organs quickly should also be considered. Grafts from victims who did not achieve ROSC did just as well at 30 days, 1 year and 5 years as those from patients who did.
BIBLIOGRAPHY
Callaway, CW, Donnino MW, Fink EL, Gieocadin RG, Golan E, Kern KB, Leary M, meurer WJ, peberdy MA, thompson TM, Zimmerman JL. Part 8: post cardiac arrest care: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(suppl 2):S465-‐S482. Circulation.2015;132(suppl 2):S383-‐S396.DOI: 10.11161/CIR.0000000000000000000262)
SECTION 7 -‐ ACUTE CORONARY SYNDROMES LEARNING OBJECTIVE: After completing this section, the student will be better able to recognize acute coronary syndromes including unstable angina and myocardial infarction. The student will demonstrate knowledge of how to treat the myocardial infarction patient to prevent cardiac arrest or preventable complications. Acute Coronary Syndromes includes Acute ST Elevation Myocardial Infarction, Unstable Angina and Non ST Elevation Myocardial Infarction. Each one carries with it challenges for the health care provider. Pre-‐hospital Management Prompt diagnosis and treatment offers the greatest potential benefit for myocardial salvage in the first hours of STEMI; and early, focused management of unstable angina and NSTEMI reduces adverse events and improves outcome. Potential delays occur in three areas:
1. Patient recognition 2. Pre-‐hospital transport 3. Emergency department
Initial Care • Half the patients who die of ACS do so before reaching the hospital. VF or
Pulseless VT is the cause of most of these deaths. Rapid access to an AED and CPR is paramount. Dispatchers should be educated in the provision of CPR instructions.
• Dispatchers should instruct patients with no history of aspirin allergy and without signs of active recent GI bleeding to chew an aspirin (160mg to 325mg) while awaiting the arrival of EMS
• Oxygen therapy is indicated only if oxygen saturation is less than 94% or the patient is short of breath or has obvious signs of heart failure
• Aspirin (160-‐325mg) should be administered (if not already done by dispatch)
• Nitroglycerin at intervals of 3-‐5 minutes to a total of 3 doses. Nitrates are contraindicated with systolic blood pressure less than 90 or right ventricular infarction. For that reason extreme caution should be used in patients with STEMI from inferior wall infarction. The diagnosis can be suspected by moving V4 (left) to V4r (right). If there is elevation of 1mm or greater, NTG should be withheld. This will not catch all RV infarction, but will catch those that are large enough to cause complications with the administration of Nitroglycerin.
• Morphine can be used in patients still having pain after NTG who are having an MI. Caution should be used in patients with unstable angina as it is associated with an increase in mortality in a large registry study.
• 12-‐Lead ECG speeds the diagnosis, shortens the time to reperfusion. All patients with signs and symptoms of ACS should have a 12-‐Lead and it should be either transmitted for remote interpretation by a physician or screened for STEMI by properly trained paramedics. A large study showed that allied healthcare providers such as paramedics are able to interpret 12 Lead ECGs in the field reliably. Therefore if the ECG cannot be transmitted to validate interpretation, the cardiac catheterization laboratory should be called in based o the allied healthcare provider’s interpretation.
Triage and Transfer • 40% of patients with MI, the EMS provider establishes first medical contact • Direct triage from the scene to a PCI capable hospital may reduce the time to
definitive therapy and improve outcome. In a large historically controlled clinical trial the mortality rate was significantly reduced (8.9% vs. 1.9%) when transport time was less than 30 minutes.
• If PCI is the chosen method of reperfusion for the pre-‐hospital STEMI patient, it is reasonable to transport patients directly to the nearest PCI facility bypassing closer EDs as necessary, in systems where the time intervals between first medical contact and balloon times are <90 minutes and transport times are relatively short (<30 minutes.)
• The combined administration of rtPA followed by transfer for emergent cardiac catheterization was associated with increased mortality and morbidity. For that reason it is not recommended as a plan of care.
Note: In systems where the Emergency Department physician activates the STEMI reperfusion protocol, including the cardiac catheterization laboratory team, significant reduction in time to reperfusion are seen and the rate of “false positive” activations are infrequent ranging from 0 to 14%. Inter-‐facility Transfer – ED protocols should clearly identify criteria for expeditious transfer of patients to PCI facilities. Emergency Department Evaluation and Risk Stratification The evaluation should focus on chest discomfort, associated signs and symptoms, prior cardiac history, risk factors for ACS and historical features that may preclude the use of fibrinolytics or other therapies. A 12 Lead ECG should be completed within 10 minutes of arrival. All providers must focus on minimizing delays at this level. ED evaluation constitutes 25-‐33% of the time to treatment delay in ACS patients. Patients are divided into three groups:
1. ST segment elevation or presumed new LBBB. ST segment elevation in 2 or more contiguous leads is classified as STEMI.
2. Ischemic ST depression or dynamic T wave inversion with pain or discomfort is classified as Unstable Angina/NSTEMI
3. Non-‐diagnostic ECG with either normal or minimally abnormal T wave changes. This category of ECG is considered non-‐diagnostic.
Cardiac Biomarkers • Troponin is the preferred marker and is more sensitive than creatine kinase
isoenzyme (CK-‐MB) • High sensitivity cardiac enzymes, although very reliable should not be
utilized alone to risk stratify patients. • Elevated level of Troponin correlates with an increased risk of death and
greater elevations predict greater risk of adverse outcome • In patients with STEMI, reperfusion therapy should not be delayed pending
results of biomarkers, they are insensitive during the first 4-‐6 hours of presentation unless continuous persistent pain as been present for 6-‐8 hours.
STEMI • The primary goal of initial treatment is early reperfusion therapy. Any
adjunction therapy that is delaying the opening of the vessel should not be completed until after the vessel is open.
Unstable Angina and Non STEMI • Unstable angina and NSTEMI are difficult to distinguish initially. These
patients usually have a partially or intermittently occluding thrombus. • These patients can be treated with early invasive strategies or with more
conservative approaches depending upon physician and patient preference and various risk factors.
Normal or Non-‐Diagnostic ECG • The majority of patients with normal or non-‐diagnostic ECGs do not have
acute coronary syndrome. Patients in this category are most often at low or intermediate risk.
Initial Therapy 1. Oxygen should be administered if the patient is short of breath, signs of heart
failure, shock or saturation less than 94%. If none of those are present, oxygen is NOT necessary.
2. Aspirin – has been associated with decreased mortality rates in several clinical trials
a. Non-‐enteric coated b. Produces a rapid clinical antiplatelet effect with near total inhibition
of thromboxane A2 production. c. Reduces coronary re-‐occlusion and recurrent ischemic events after
fibrinolytic therapy d. Recommended dose: 160-‐325 mg. Chewable or soluble aspirin is
absorbed more quickly than swallowed tablets 3. NSAIDS are contraindicated and should be discontinued in patients who are
taking them. Should not be administered during hospitalization for STEMI because of increased risk of mortality, re-‐infarction, hypertension, heart failure and myocardial rupture associated with their use.
4. Nitroglycerin causes dilation of coronary arteries, peripheral arterial bed and venous capacitance vessels.
a. Treatment benefits are limited, however and no conclusive evidence supports routine use in AMI
b. Carefully considered especially with low blood pressure or when their use would preclude the use of other agents known to be beneficial such as ACE inhibitors
c. Relief of chest discomfort with NTG is neither sensitive nor specific for ACS; gastrointestinal etiologies as well as other causes of chest discomfort can respond to NTG administration.
5. Analgesia should be administered for chest discomfort unresponsive to nitrates.
a. Morphine is the drug of choice in STEMI patients b. Morphine is associated with increased mortality in patients with
unstable angina and should be administered with caution
Reperfusion Therapies • Fibrinolysis restores normal coronary flow (TIMI 3) in 50-‐60% of subjects. • PCI is able to achieve restored flow in >90% of subjects. • PCI translates into reduced mortality and re-‐infarction rates as compared to
fibrinolytic therapy making it the reperfusion strategy of choice in the elderly and those at risk for bleeding.
• Fibrinolysis can be used in patients who present within 12 hours on onset of symptoms and who lack contraindications to its use and cannot be transferred for PCI within a reasonable amount of time.
• The major determinants of myocardial salvage and long term prognosis are short time to reperfusion complete and sustained patency of the infarct related vessel with normal flow.
Complicated AMI Cardiogenic Shock, LV Failure, Congestive Heart Failure – infarction of >40% of myocardium usually results in cardiogenic shock and carries a high mortality rate. Of those who develop shock, patients with ST segment elevation developed shock significantly earlier than those without elevation. Cardiogenic shock and congestive heart failure are not contraindications to fibrinolysis, but PCI is preferred if the patient is at a facility with PCI capabilities. RV Infarction – or ischemia may occur in up to 50% of patients with inferior wall MI. The provider should suspect RV infarction in patients with inferior wall infarction, hypotension and clear lung sounds.
• Obtain an ECG with right-‐sided leads. ST elevation in lead V4R is sensitive for RV infarction and is a strong predictor of increased in hospital complications and mortality
• The in hospital mortality rate of patients with RV dysfunction is 25-‐30%, and these patients should be routinely considered for reperfusion therapy.
Adjunctive Therapies for ACS and AMI Clopidogrel (Plavix) results in a reduction in platelet aggregation through a different mechanism than aspirin. Patients with ACS and a risk in cardiac biomarkers or ECG changes consistent with ischemia had reduced stroke and major adverse cardiac events if Plavix was added to aspirin and heparin within 4 hours of hospital presentation. Plavix given 6 hours or more before elective PCI for patients with ACS without ST elevation reduced adverse ischemic events at 28 days.
• Loading dose: 300 mg PO • Maintenance: 75 mg/day
Prasugrel (Effient) – oral thienopyridine prodrug that irreversibly binds to the ADP receptor to inhibit platelet aggregation.
• Small improvement in major adverse cardiac events (MACE) when administered before or after angiography to patients with NSTEMI and STEMI
• 60 mg oral loading dose may be substituted for clopidogrel after angiography in patients determined to have non ST segment elevation ACS or STEMI who are more than 12 hours after symptom onset prior to planned PCI.
• No evidence supporting use in ED or pre-‐hospital setting. • Not recommended in STEMI patients receiving fibrinolysis or NSTEMI
patients prior to angiography
Glycoprotein IIb/IIa Inhibitors – use for treatment of patients with unstable angina and NSTEMI has been well established.
• Documented benefit in patients with elevated Troponin and a planned invasive strategy or specific patients with diabetes or significant ST depression on presenting ECG.
Beta Adrenergic Receptor Blockers – several studies have shown reduced mortality and decreased infarction size with early beta blocker administration.
• Recommend beta blockade within 24 hours of hospitalization • Contraindicated in moderate to severe LV failure and pulmonary edema,
bradycardia (<60) and hypotension (<100 mmHg), poor peripheral perfusion or second or third degree heart block
• For STEMI there is no evidence to support the routine administration in the pre-‐hospital environment or during the initial ED assessment.
Heparins – is an indirect inhibitor of thrombin that has been widely used in ACS as adjunctive therapy for fibrinolysis and in combination with aspirin and other platelet inhibitors for the treatment of non ST segment elevation ACS. Treatment with Heparin should continue for at east 48 hours. ACE Inhibitors – has improved survival rates in patients with AMI, particularly when started early after the initial hospitalization. The beneficial effects are most pronounced in patients with anterior infarction, pulmonary congestion or LV ejection fraction less than 40%. Although ACE inhibitors and ARB’s have been shown to reduce long term risk of mortality in patients suffering AMI, there is insufficient evidence to support the routine initiation of therapy in the pre-‐hospital or ED setting. HMG Coenzyme A Reductase Inhibitors (Statins) – there is little data to suggest that this therapy should be initiated within the ED; however early initiation (within 24 hours of presentation) of statin therapy is recommended in patients with an ACS or AMI. If patients are already on statin therapy is should be continued.
BIBLIOGRAPHY O'Connor RE, Brady W, Brooks SC, Diercks D, Egan J, Ghaemmaghami C, Menon V, O'Neil BJ, Travers AH, Yannopoulos D. “Part 10: acute coronary syndromes: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care”. Circulation. 2010;122(suppl 3):S787–S817. http://circ.ahajournals.org/content/122/18_suppl_3/S787 O’Connor RE, Al Ali AS, Brady WJ, Ghaemmaghami CA, Menon V, Welsford M, Shuster M. Part 9: acute coronary syndromes: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(suppl 2):S483-‐S500. Circulation.2015;132(suppl 2):S383-‐S396.DOI: 10.11161/CIR.0000000000000000000263.)
SECTION 8 -‐ ADULT STROKE LEARNING OBJECTIVE: After completing this section, the student will be able to demonstrate the ability to assess the patient experiencing stroke like symptoms to determine the need for transportation to an appropriate stroke center. The student will be able to utilize the Cincinnati Prehospital Stroke Scale. The D’s of Stroke Care are the major steps in diagnosis and treatment of stroke and identify the key points at which delays can occur: (Jaunch et al.)
• Detection – Rapid recognition of stroke symptoms • Dispatch – Early activation and dispatch of emergency medical services by
calling 911 • Delivery – Rapid EMS identification, management and transport • Door – Appropriate triage to stroke center • Data – Rapid triage, evaluation, and management within the emergency
department • Decision – Stroke expertise and therapy selection • Drug – Fibrinolytic therapy, intra-‐arterial strategies • Disposition – Rapid admission to stroke unit, critical care unit
The time sensitive nature of stroke care is central to the establishment of successful stroke systems. GENERAL: The logic of having a multi-‐tiered system such as that provided for trauma works best. There will be primary stroke centers and comprehensive stroke centers and the new concept of a stroke prepared hospital can access stroke expertise via telemedicine. Several states have passed legislation requiring pre-‐hospital providers to triage patients with suspected stroke to designated stroke centers. The integration of EMS into regional stroke models is crucial for improvement of patients’ outcomes. 911 and Dispatch – provide education and training to 911 and EMS personnel to minimize delays in pre-‐hospital dispatch, assessment and transport. High priority dispatch to patients with stroke symptoms
• Where ground transport to a stroke center is potentially long, air medical services may be used.
Assessment The Cincinnati Prehospital Stroke Scale has a sensitivity of 50% and a specificity of 89% when scored by Prehospital providers. The provider first rules out other causes such as hypoglycemia and seizures and then evaluates three areas:
1. Facial droop 2. Arm Drift 3. Abnormal Speech
4. Last known well (absolutely essential in determining appropriate intervention)
With education paramedics demonstrated a sensitivity of 61-‐66% for identifying patients with stroke. Pre-‐hospital Management and Triage
• Must clearly establish time of onset of symptoms. Defined as the last time the patient was observed to be normal
• Supplemental oxygen if saturation less than 94% or shortness of breath • Unless patient is hypotensive (systolic less than 90 mmHg) no intervention
for blood pressure is recommended. • Should consider transporting a witness or family member with the patient to
verify time of onset • Pre-‐arrival hospital notification has been found to significantly increase the
percentage of patients with acute stroke who receive fibrinolytic therapy • Significantly larger percentages of patients receive rtPA when transported
directly to stroke centers
A growing body of evidence indicates a favorable benefit from triage of stroke patients directly to designated stroke centers. EMS systems should establish a stroke destination preplan to enable EMS providers to direct patients with acute stroke to appropriate facilities. When multiple stroke hospitals are within similar transport distances, EMS personnel should consider triage to the stroke center with the highest capability of stroke care. Multiple randomized clinical trials and meta analysis in adults document consistent improvement in one year survival rate, functional outcome and quality of life when patients hospitalized for stroke are cared for in a dedicated stroke unit by a multidisciplinary team experienced in management of stroke. When such a facility is available within a reasonable transport interval, stroke patients who require hospitalization should be admitted there. (Class I) In-‐Hospital Care – Initial ED Assessment and Stabilization
• Protocols should be used to minimize delay to definitive diagnosis and therapy
• Assessment should be complete within 10 minutes of arrival • Obtain IV access, draw blood for baseline studies • Identify and treat hypoglycemia • Obtain a neurologic screening assessment • Emergent CT scan of the brain • Activate the stroke team or arrange consultation with a stroke expert
• 12 lead ECG does not take priority but can help identify recent infarction or arrhythmia as case of embolic stroke
• Cardiac monitoring during the first 24 hours of patients with ischemic stroke is recommended to detect atrial fibrillation and potentially life threatening arrhythmias
Hypertension Treatment Management of hypertension in the stroke patient is dependent on the fibrinolytic eligibility. For patients potentially eligible for fibrinolysis, blood pressure must be <185 mmHg systole and <110 mmHg diastolic to limit the risk of bleeding complications. Imaging – CT should be completed within 25 minutes of arrival and interpreted within 45 minutes of ED arrival Fibrinolytic Therapy
• Assess for exclusion criteria • The major complication is intracranial hemorrhage. Occurred in 6.4% of 312
patient study and 4.6% of 1135 in another trial • A higher likelihood of good to excellent functional outcome when rtPA is
administered to adult patients with acute ischemic stroke within 3 hours of onset of symptoms
o Treatment of CAREFULLY SELECTED patients with acute ischemic stroke with IV rtPA between 3 and 4.5 hours after onset of symptoms has also been shown to improve clinical outcome, although the degree of clinical benefit is smaller than that achieved with treatment within 3 hours.
BIBLIOGRAPHY Jauch EC, Cucchiara B, Adeoye O, Meurer W, Brice J, Chan Y-‐F, Gentile N, Hazinski MF. “Part 11: adult stroke: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care”. Circulation. 2010;122(suppl 3):S818–S828. http://circ.ahajournals.org/content/122/18_suppl_3/S818