- 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.
- 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!
- 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!
- 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 (?)
- 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