New Practices in ACLSNew Practices in ACLS

Rapid FireRapid Fire

Jason Persoff, MDJason Persoff, MD

Assistant Professor of Hospital Internal MedicineAssistant Professor of Hospital Internal Medicine

Mayo Clinic JacksonvilleMayo Clinic Jacksonville

Evidence-Based Rapid Fire

What new changes to BLS should I be implementing in the hospital setting?

What new recommendations related to medications provided during ACLS do I need to know?

Should family members be present during a code?

ACLS Medications

ACLS Medications

Antiarrhythmics Increase QTc Increase risk of cardiac arrest Do antiarrhythmics promote survival in IHCA?

Bloom: amiodarone improves survival Most others: survival to hospital discharge is lower

Bloom et al. Am J Heart 2007 Pollak et al. Can J Card 2006 VanWalraven et al. Ann Emerg Med 1998

ACLS Medications

Medications that have shown survival Beta Blockers ACEI

Bloom et al. Am J Heart 2007

Vasopressin Pediatrics: survival improved Adults: seen in higher proportion of non-survivors

Stiell et al. Lancet 2001 DeMos et al. Crit Care Med 2006 VanWalraven et al. Ann Emerg Med 1998

ACLS Medications Calcium

Administration occurs higher in non-survivors Bicarbonate

Higher rates of death in IHCA Atropine

Higher rates of death in IHCA Magnesium

No changes in survival in any subgroup VanWalraven et al. Ann Emerg Med 1998 DeMos et al. Crit Care Med 2006 Thel et al. Lancet 1997

ACLS Medications

ACLS MedicationsShockable Rhythm?

Yep

V-Fib

Pulseless VT

Have no idea

Nope

PEA

Asystole

360JMono

150JBiphasic

150JBiphasic

or

5 Cycles

(150 Compressions)

Shock

Drug

Shock

Pressor (Vasopressin or Epi)

Antiarrhythmic (Amiodarone)

Family Presence on a CODE

Nursing staff believe families should be present on codes (>75%)

Kuzin et al. Pediatrics. 2007 Oct;120(4):e895-901

Best review: Critchell and Marik Am J of Hospice Pall Med 2007

2008: The Revolution Begins

Bardy, et al. Home use of automated external defibrillators for sudden cardiac arrest. NEJM 2008; 358: Online only at http://www.nejm.org/. April 1, 2008

Sayre, et al. Hands only (compression-only) CPR. Circulation 2008; 117: Online only at http://circ.ahajournals.org/. April 1, 2008

Peberdy, et al. Survival from in-hospital cardiac arrest during nights and weekends. JAMA 2008; 299: 785-792.

Chan, et al. Delayed time to defibrillation after in-hospital cardiac arrest. NEJM 2008; 358: 9-17.

Epidemiology

88% of inpatient cardiac arrest (IHCA) occurs in patients with DNR orders

12% undergo resuscitation 1.25-3.8 per 1000 admissions Most occur in ICU (45%) Few arrests are unwitnessed (12%)

Sandroni et al. Resuscitation 2004.

Epidemiology

Demographics of 37,782 inpatient cardiac arrests Nadkarni et al., JAMA 2006; 295

Age (y) ± SD (age range) 65.3 ± 15.2 (18-111)

Male Gender 57%

CaucasianBlack

HispanicOther

67%20%5%8%

Medical (Cardiac)Medical (Non-Cardiac)

Surgical (Cardiac)Surgical (Non-cardiac)

Trauma

18%46%17%7%10%

Prognosis Terminology

ROSC (Return of spontaneous circulation) SHD (Survival to hospital discharge) NIS (Neurologically intact survival)—CPC 0 or 1

NIS Cerebral Performance Category (CPC)

0 Normal 1 Good 2 Moderate disability (Caffeinated) 3 Major disability 4 Persistent vegetative state, coma 5 Brain death 6 Me post-call

Prognosis

Pure respiratory events SHD (reference) OR 1.0 Vs. VF/VT Arrest: OR 4.2 (1.4-12.5) Vs. Asystole/PEA Arrest: OR 21.0 (6.2-71.7)

Brindley et al. CMAJ 2002.

Prognosis

Ventricular Fibrillation/Tachycardia ROSC 54-76% SHD 16.5-57% NIS 58-75%

PEA/Asystole Arrests ROSC 43-52% SHD 10-20% NIS 61-62%

Prognosis

Discrepancies Men are twice as likely to have VF than women

Herlitz et al. Resuscitation 2002.

Women are more likely to survive (OR 1.66, 1.06-2.62)

Herlitz et al. Resuscitation 2001.

Blacks have a lower likelihood of SHD Ebell et al. J Fam Prac 1995.

Blacks had statistically robust delays in defibrillation Chan et al. NEJM 2008.

Prognosis

“It’s a good time to die.”—Some action movie 1500 “Golden Hour”

Bad time of day: nighttime Survival lowest 2300-0700

Brindley et al. CMAJ 2002.

Nocturnal arrest has half the likelihood of SHD Herlitz et al. Resuscitation 2002.

More likely due to asystole/PEA Peberdy et al. JAMA 2008.

Prognosis

Nocturnal IHCA Less likely to have ROSC (44.7% vs. 51.1%) Less likely to survive 24 hours (28.9% vs. 35.4%) Less likely to SHD (14.7% vs. 19.8%)

Weekend Commensurate to nocturnal survival

Basic Life Support CPR when done perfectly provides only…

1/3 normal cardiac output 10-15% normal cerebral blood flow 1-5% normal cardiac blood flow

Sanders et al. 1985.

Goals Push hard Pump fast Good recoil

How many push ups can you do? Rotate rescuers

Basic Life Support

In swine… Rapid compressions:

80/min 10% survival at 24 hrs 100/min 100% survival at 24 hrs

Yu et al. 2002.

Continuous vs. Classic Better coronary perfusion pressures Higher “neurologically normal” function

Kern et al. 2002

Basic Life Support

Compressions too shallow 62.6% of the time Compressions too slow 71.9% of the time

Abella et al. 2005.

CPR Good: Survival at 14d: 16% CPR Bad: Survival at 14d: 4%

VanHoeyweghen et al. 1993.

Basic Life Support

Delay in chest compressions = death CPR started < 1 minute after collapse: SHD 34% CPR started 1 minute after collapse: SHD 14%

Skrifvars et al. Resuscitation 2006

Code team arrival delay of >2 minutes after arrest: SHD begins to decrease

Code team arrival >6 minutes after arrest: SHD 0% Sandroni et al. Resuscitation 2004

Basic Life Support What is the appropriate tidal volume for a patient in

cardiopulmonary arrest? 10cc/kg, or roughly 750cc

What is the volume of an adult bag-valve-mask? 1.5 liters Designed for 1-handed operation

ETT is misplaced 6-14% of the time Katz et al. Ann Int Med 2001.

“Iatrogenic hypotension” Over-zealous BVM use due to

Desire to correct hypoxia Belief that hyperventilation will correct acid-base derangements

Basic Life Support

Rate exceeded at least 60.9% of the time in humans

In swine models, hyperventilation resulted in… …increased intrathoracic pressure …decreased coronary perfusion pressures …lower survival

Aufderheide, et al. 2004.

Basic Life Support Phenomenon of auto-PEEP usually referred

to patients on a ventilator

                                                            

Basic Life Support

Michard F. Anesthesiology 2005

Basic Life Support

Current clinical controversy Should we ventilate at all?

April 1, 2008 No…compressions only in layperson resuscitation Most animal models show NO BENEFIT to

ventilations plus ventilations to compressions only In humans

Equivalent SHD in typical and compression-only CPR 1-year NIS similar

Basic Life Support

Striking the balance No oxygenation without circulation The longer resuscitation is attempted, the lower the

oxygen level Threshold appears to be 4 minutes into an arrest

Delivery of as little as 2 breaths : 100 compressions after 4 minutes of continuous compressions had better outcomes

Sanders et al. Ann Emerg Med 2002.

Interesting aside…Why don’t people do CPR? Only 1.4% of bystanders feared disease

Conclusions?