AHAACLSGuideline

Update
AmericanHeartAssociationAdvance
CardiacLifeSupport

OutofHospitalCardiacArrestDatain
HongKong(Ref:HKJEM,HKMJ2002)
15%patientdiebecauseofACS
5 18%initialrhythmisVF
70 90%initialrhythmisasystole
14%canbesurvivaltoadmissiontoA&E
0.5 3%canbesurvivaltodischarge
42 80%witnessarrest
12%citizenlearnedCPR
15%BystanderCPRrate
Out of hospital cardiac arrest
2005 (PWH):
* Most of OHCA happens at home
* Bystander CPR ~15.3%
* Most common 1st rhythm identified: asystole;
VF/VT only 18%
* Overall survival 0.8% (VF/VT: 11.8%, Asystole
0%)
* Median time of 1st shock: 14 minutes; Median
time of arrival to hospital: 33 minutes
In-hospital cardiac arrest
2007 (PWH)
* Most occurred in non-monitored area
* Initial rhythm mostly asystole (52%)
* Only 8% VF/VT; (40% PEA)
* Overall survival rate 5%
* Survival rate higher in monitored area (9% vs 4%),
respiratory arrest (61% vs 3%), Initial rhythm VF/VT
(13% vs 4%)
2006 (Taiwan)
* overall 18%STD (Survival to Discharge)
2009 (USA)
* VF survival rate 8-40%depending on the region
2002(HK)
0.5 3% canbesurvivaltodischarge!!
i.e.themortalityofOHCAinHKis97 99%!!
Why??Delayinrestorationofnormalrhythmand
circulation.
Howtoimprove??
Call99912minAmbulanceofficerarrivedwitha
defibrillator(equippedsince1990s)
Evidence:75%VFcanberevivedifdefibrillation
within3min.
PublicaccessAEDsaved50%morelivesfromOHCA
TheHKCCAEDProgramsince2008:increasepublic
awareness,promotelaypersontraininginBLSand
coordinateAEDinstallationinsuitablelocation
ResuscitationCouncilofHongKongestablishedin
May2012(Titleofthe1
st
scientificmeeting:Public
AccessDefibrillation)
Incardiacarrest...NewChainsofsurvival
Survival fromcardiacarrestrequires:
Rapid,highqualityBLS(Mostchange)
EarlydefibrillationforVF/pulselessVT(efforttoimprove)
SystematicACLSinterventions,with
BasisonhighqualityCPR,withminimallyinterrupted
chestcompression
ContinuousmonitoringofCPRquality
Drug/advancedairway/underlyingcauses
Rhythmbasedalgorithms
Integratedpostcardiacarrestcare(NewLink)
OddsRatiosforSurvivaltoHospitalDischarge
AssociatedwithSelectedFactors
OriginalArticlefromTheNewEnglandJournalofMedicine AdvancedCardiacLifeSupportin
OutofHospitalCardiacArrest.Aug12,2004
Howimportantofeachring?
1
st
Link:earlyaccessbybystander:4.4
2
nd
Link:earlyCPRbybystander:3.7
3
rd
Link:defibrillationin<8min:3.4
4
th
Link:Advancedlifesupport:1.1
BLSClip
Push hard
(Depth >5cm)
Push fast
(Rate >100min)
Ensure
complete
chest recoil
Minimally
interrupted
chest
compression
Avoid
hyperventilation
(ventilate 8 10/min)
(decrease survival rate)
Rotate
compressor
every 2 mins.
(avoid fatigue)
Compression:
Ventilation
30:2
(Vs old 15:2)
High Quality
CPR
BLS
Physiologyofcirculationduring
standardCPR
C.O.(cardiacoutput):depressed1030%
Brain bloodflow:depressed20%
Coronary bloodflow:5 15%
LowerlimbsandAbdvisceralflow:<5%
Bloodflowgeneratebychestcompressionisso
weakthatanyinterruptioneg.Breathingwill
lowerthesurvivalrate
Thus:anyinterruptionofCPRshouldbeminimized
CAB (OldABC)
1. Checkforresponsivenessandbreathing
2. CallforhelpandgettheAED
3. Checkthepulse
4. Give30chestcompressions(step1to3donein10seconds)
5. Opentheairwayandgive2breaths
6. Resumecompressions
(Evidenceshowsthatcompressionsarethecriticalelementin
adultresuscitation.IntheABCsequence,compressions
areoftendelayed.Layrescuersdifficulttoassessbreathing.)
Circulation 2008; 117:2162-2167
Resuscitation 2008; 78: 119-126
Change of BLS
Change of BLS
Continuous Chest Compression(CCC)orcalled
HandsonlyCPRisasgoodasconventionalCPRfornon
medicalbystanders***(2008)
HandsonlyCPRbetterthannoCPR
Why??Studieshaveshownthat:
bystandersaremorewillingtostartresuscitationifmouthtomouth
ventilationarenotrequire.(nowonly25%cardiacarrestpatientreceives
bystanderCPRinUS)(15%inHK)
CCCiseasytolearn.
Passivechestrecoilprovideairexchange.
Arterialoxygenstoresdepletein4mininCCC.
Exceptrespiratoryarrest.eg.COpoisoning,severeasthma,drowningetc.
inwhichconventionalCPRshouldbeemploy
Alternativetechniqueanddevices
Severalalternativetechniqueanddevicesto
conventionalmanualCPR
Efficacyreportedinspecificsettings
Noalternativetechniqueordevicesinroutine
useconsistentlyshowedsuperiorityover
conventionalmanualCPR***
BLS
LUCAS LundUniversity
CardiopulmonaryAssistSystem
LUCASvsmanualCPR:equivalentandsafe
Experimentalstudiesshownimprovementofperfusion
pressuretothebrainandheart.
2randomisedpilotstudiesinoutofhospitalcardiac
arrestpatientshavenotshownimprovedoutcome.
AED AutomatedExternal
Defibrillator
Defibrillationistheonlyrhythmspecificintervention
thatincreasechanceofsurvivaltohospitaldischarge
UseAEDimmediatelyonceavailable
CompulsoryaperiodofCPRbeforeusingAED(old)is
notrecommend.
Outcomesofrapiddefibrillationby
securityofficersaftercardiacarrestin
casinos.NEJM2000
105patientsinVFin32LasVegasCasinos
3.5+/2.9minfromcollapsetoattachAED
4.4+/2.9minfromcollapsetofirstshock
9.8+/4.3minfromcollapsetoarrivalofEMT
74%survivaliffirstdefib<3min
49%survivaliffirstdefib>3min
MaxiumdoseofDefib?
HKJEM2005.AcaseofpersistentandrecurrentVF
withsuccessfulresuscitationandgoodneurological
outcome
Case:49/M,retrosternalchestpain,witnessarrestin
A&EwithVF.
Totalshocks:22(21inA&E,1inICU)
Dx:AMI
DConD10,goodneurologicaloutcome
ACLSClip
ACLS:4CategoriesofChange
CardiacarrestAlgorithm
ImmediatePostCardiacarrestCareAlgorithm
AirwayManagement
SynchronizedCardioversion
Emphasizetheimportanceofhighquality
CPR
Theonlyrhythmspecifictherapythatis
proventoincreaseSTDisdefibrillation
ACLSactions(vascularaccess,medication
deliveryandadvancedairwayplacement)
shouldnotinterruptCPRandDefibrillation
Other ACLS therapies: medication and
advanced airway, improve the chance of
ROSC, but not the chance of STD
Further evaluation of the role of these
therapies is necessary, especially with the
higher-quality CPR and better post-arrest
care re-emphasis after 2010
Cardiacarrestalgorithm2010
GOOD
ACLS
bases
on
GOOD
BLS
MonitoringCPRquality
MonitoringCPRquality
Physiologicalparameters
EndtidalCO2(PETCO2)
Correlatewithcardiacoutputandmyocardialblood
flowduringCPR
EndtidalCO2(PETCO2)
ConsiderthepresenceofROSC(ReturnOf
SpontaneousCirculation),ifPETCO2 abruptly
increasestoandsustainedat3540mmHg
PETCO2 persistently<10mmHg suggestslow
likelihoodofROSC
ConsiderimprovingCPRqualityifPETCO2
<10mmHg
OptimalPETCO2 duringCPRuncertain
Airwaymanagement
Airwaymanagement
Advancedairwayplacementincardiacarrestshouldnotdelay
initialCPRanddefibrillationforVF
Optimaltimingofadvancedairwayplacementduring
resuscitationundefined
Interruptionofchestcompression(ideally<10seconds)vs
needforinsertionofadvancedairway
SupraglotticairwayasaneasieralternativetoETtube
Earlyvslateadvancedairwayplacement Inhospital
cardiacarrest:
NostatisticallysignificantdifferenceintermsofROSC
?Beneficialintermsofsurvivaltohospitaldischarge
Airwaymanagement
ETtube
Supraglotticairways
LMA
LaryngealTube
Noevidencethatadvancedairwayimprovessurvival
inoutofhospitalcardiacarrest
Capnography
Recommendedfor
ConfirmingandmonitoringcorrectplacementofETtube,
(inadditiontoclinicalassessment)
MonitoringCPRquality
DetectingROSC
Capnography
Confirmation of tube placement
Monitoring of CPR quality and detecting ROSC
PETCO2 persistently <10mmHg;
need to improve CPR quality
Sustained PETCO2 >35-
40mmHg
Drugtherapy
Associated with increased rate of ROSC
and survival to hospital admission, but not
increased rate of neurologically intact
survival to hospital discharge
IV/IO/ETaccess
LessimportantthanhighqualityCPR
Performwithoutinterruptingchestcompression
Insufficientevidencetospecifytheoptimaltimeand
sequenceofdrugsadministrationduringcardiacarrest
ProvideIOaccessifIVaccessnotreadilyavailable
ETrouteonlyifIVandIOaccesscantbeestablished
Rhythmbased Algorithm
2005 2010
VF/PulselessVT
Defibrillationimprovessurvival
Emphasize:
1shockevery2mins.
Minimizehandsofftime
Continuechestcompressionwhilechargingdefibrillator
ResumeCPRimmediatelyaftershockdeliverywithoutpulse/rhythm
check
VF/PulselessVT
Energydose
120200J,accordingtomanufacturersrecommendation
(Biphasic)
Subsequentenergylevelequivalentorhigher
360J(Monophasic)
VF/PulselessVT
Nochangeinmedication
Adrenaline
Vasopressin
Antiarrhythmicagent
Amiodarone
(Lignocaine)
MgSO4(ForTdPonly)
VF/PulselessVT
Precordialthump
Roleincardiacarrestuncertain
Maybeconsideredforwitnessed,monitoredVF/
pulselessVTwhenadefibrillatorisnotreadily
availableforuse
PEA/Asystole
Atropine
Therapeuticbenefitunlikely
Searchforunderlying
causesinPEA(5H5T)
Hypervolemia
Hypoxia
Hydrogenion(acidosis)
Hypo(hyper)kalemia
Hypothermia
Tensionpneumothorax
Tamponade,cardiac
Toxins
Thrombosis,pulmonary
Thrombosis,coronary
Bradycardia
2005 2010
Bradycardia
Atropineasfirstline
Ifatropinefail:
TCPastemporizing
measure
Alternative:dopamine,
adrenaline
Tachycardia
2005 2010
Tachycardia
Immediatesynchronized
cardioversionforunstable
tachyarrhythmia
120200JforAF
100JformonomorphicVT
50100Jforatrialflutter/other
SVT
Unsynchronizedshockforunstable
polymorphicVT
Tachycardia
ATPcanbeconsideredfor
undifferentiatedregular,
monomorphicwide
complextachycardia(Class
IIb,LOEB)
PostCardiacArrestCare
PostCardiacArrestCare
Increasingevidencethat
asystematicmulti
disciplinarypostcardiac
arrestcareafterROSC
increaseslikelihoodof
neurologicallyintact
survivaltohospital
discharge
The only intervention
demonstrated to improve
neurologically intact
recovery
TherapeuticHypothermia
Inductionofhypothermia(3234)for1224hoursfor
thoseremaincomatoseafterROSC,withinitial:
OutofhospitalVFarrest(ClassI)
Inhospitalarrestofanyrhythm(ClassIIB)
Outofhospitalasystole/PEA(ClassIIB)
SupplementaryO2afterROSC
WeanFiO2whenSaO2100%
TitratesupplementaryoxygentomaintainSaO294%
99%
GlycemicControl
Hyperglycemiaassociatedwithhighermortalityand
worsenedneurologicaloutcome
Maintainserumglucoselevel810mmol/L
SeizureManagement
Seizuremayoccurin520%ofcomatosecardiacarrest
victimsafterROSC
EEGfordiagnosisandfrequentmonitoringin
comatosepatientsafterROSC(ClassI,LOEC)
Stroke
Stroke
Stroke
Dedicatedstrokeunit
Improve1yearsurvivalrate,functionaloutcomeand
QualityofLifeforstrokepatients
Fibrinolytictherapy(IVrtPA)forischemicstroke
TimeisBrain theearlier,thebetter
FDAapprovedifrtPAisusedwithin3 hours ofstroke
onsetineligiblestrokepatients
AcuteCoronarySyndrome
AcuteCoronarySyndrome
Whatisnew?
Alargeregistryshowedanassociationbetween
morphine andUA/NSTEMIandincreasedmortality
NomoreroutineMONA:startO2ifSaO2<94%
Emergentangiographywithpromptrevascularization
oftheinfarctrelatedarteryisrecommendedforoutof
hospitalVFcardiacarrest(ClassI,LOEB)
AcuteCoronarySyndrome
Timeismuscle:AMI<12hrreperfusiontherapy
Coronaryreperfusionwith:primarypercutaneous
coronaryintervention(PCI)VsFibrinolysis(depend
onresources)
Reperfusiongoals:
PCI(Doortoballooninflationgoal:90min);
Fibrinolysis(DoortoNeedlegoal:30min)
Wheretotakethecourse?
HospitalAuthorityAccident&EmergencyTraining
Centre
www3.ha.org.hk/aetc
Location:TangShiuKinHospital,WanChai
Whatarethecourses?
Coursesforhealthcareprofessional
AdvancedStroke LifeSupport(ASLS) Hospital
Provider
AmericanHeartAssociation(AHA)BasicLifeSupport
(BLS)Provider/Renewal
AHAAdvancedCardiacLifeSupport(ACLS)Provider
/Renewal
AHAPediatric AdvancedLifeSupport(PALS)
Provider/Renewal
AmericanAcademyofPediatricNeonatal
ResuscitationProgram(NRP)
InternationalTrauma LifeSupport(ITLS)Advanced
SimulatedAccident&VehicleExtrication(SAVE)
(ITLSAccess)
EmergencyManagementofSevereBurns (EMSB)
AHAECG (singleleadforcardiacmonitoring)
VenousCannulation&Bloodtakingfornurse
CrewResourceManagement
12leadECG Interpretationfornurses
Transportation andRetrievalofIllpatient(TRIP)
UnderstandingEmergencyXRay(ForHealthCare
Professional)
EmergencyDelivery Care(ED)HospitalProvider
QuestionsandComments?