Updates in ACLS

  • ETCO2 monitoring in ACLS
  • Limited roles of meds
  • Body temperature mgmt post-resuscitation
  • Airspeed of an unladen swallow = 20-22 mph
Both ERC and AHA share identical guidelines for BLS.
  • Pulse check for 10 sec
  • Compression rate 100-120 per minute
  • Ratio 30:2 compression to breaths
  • Give naloxone
  • Shock shockable rhythms
The Pulse Check:  only 58% of the time could a clinician accurately assess whether someone has a pulse!  About half the time this would have resulted in no CPR.
  • When combined with assessment of respirations (present or absent), accuracy went way up!
SO…IF A PATIENT IS UNCONSCIOUS AND IN DISTRESS (BLUE, GUPPY BREATHING, LOOK DEAD) – START CHEST COMPRESSIONS IMMEDIATELY.
SHOCK IT UNTIL YOU RECOGNIZE THE RHYTHM
  • If you shock a non-shockable rhythm, it’s likely you’ll shock it into a shockable rhythm!
In 2010, ABCs were changed to CABs to emphasize importance of compressions.
In 2015:  passive insufflation with a NRB mask (and an oral airway) with continuous chest compressions for certain out-of-hospital EMS resuscitations.
  • Continuous chest compressions result in steadily increasing aortic pressure, which feeds the coronary arteries.  When compressions stop, the aortic pressure is lost.
  • Also, BVM ventilations reduce aortic and coronary blood flow.
Gasping –> intense negative inspiratory pressure, and IMPROVED cerebral blood flow!  So, gasping from cardiac arrest probably has a physiologic survival function.
  • So, if the patient is gasping – put O2 on them.
  • If the patient is NOT gasping, use a BVM.
 
HOW DO WE BALANCE THE NEED FOR CHEST COMPRESSIONS AND THE NEED FOR O2 DELIVERY AND VENTILATION?
  • QI studies have shown that even in great hospitals, the compression time fraction is around 20%!
  • Goal is to get compression time > 60%.
  • So long as chest compressions are emphasized, minimal interruptions to compressions don’t seem to adversely affect outcomes.
  • Chest compressions and electrical therapy (shocking) should ALWAYS be first priority in adult cardiac arrest.
AIRWAYS
  • Endotracheal tubes were first used (and published in the BMJ) in 1880.
  • In the prehospital and inpatient setting, BAGGING THE PATIENT IS SUPERIOR TO INTUBATING THE PATIENT.
  • Patients who have no advanced airway survived at a HIGHER rate than those who got an advanced airway!  There is no rush to intubate people.  There is no evidence of improved survival with immediate intubation vs waiting 5-10 minutes.
  • What’s the problem?  Invasive airway management often interferes with what matters most – compressions!
COMPRESSIONS
  • ERC and AHA both emphasize that quality compressions are vital.
  • Start ASAP
  • Push hard
  • Pump fast (100-120/min)
  • Good recoil
  • Minimize interruptions (>60% of the resuscitation)
  • EtCO2 monitoring to monitor quality of compressions
So far, studies have not showed compression machines (thumpers) to be superior to humans.
END-TIDAL CO2 MONITORING
  • These things should be on every code cart (but they’re not).
  • ETCO2 should bump up to 10-20 with adequate chest compressions (delivery of hypercarbic blood to the lungs)
  • If the ETCO2 bumps up to 40+, this can signal ROSC, so check a pulse!
 
SHOCKING
  • Stop compressions, analyze, re-start compressions, deliver shock, immediately restart compressions.
ADVANCED CARDIAC LIFE SUPPORT
  • Emphasis on quality CPR
  • Rotate rescuers doing compressions q 2 minutes
  • NO MORE RECOMMENDATION FOR VASOPRESSIN
    • No vasopressor has EVER been shown to improve survival to hospital discharge neurologically intact
    • Epinephrine continues to be recommended based on one RCT of out-of-hospital arrest and small case studies
    • Epi should be given ASAP in resuscitation
  • Use ETCO2
  • What about steroids?
    • JAMA 2013 – vasopressin-steroids-epinephrine shown to improve survival outcomes in two studies from one center in Greece.  Problem is – no one has been able to replicate the results.
    • Vasopressin 40 U + epinephrine 1mg + methylprednisolone 40mg (?)
  • Hypothermia
    • Prior studies suggested improved neuro outcomes with post-arrest hypothermia (32-34 C).
    • New data suggest 36C has equivalent outcomes
    • So, new guideline:
      • Maintain 32-36 C in all patients post VT/VF arrest
      • Avoid fevers
      • For any ST elevation, early PCI is strongly recommended
JAMA 2016 Oct 7 (ish)
     – Therapeutic post-arrest hypothermia had WORSE outcomes – favorable neuro status at discharge and 1-year survival:  17% with hypothermia vs 20% without hypothermia!
 – From Rocky Mountain Hospital Medicine conference, 2016, Persoff
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