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??
Call999 12min Ambulanceofficerarrivedwitha

defibrillator(equippedsince1990s) Evidence:75%VFcanberevivedifdefibrillation within3min. PublicaccessAEDsaved50%morelivesfromOHCA TheHKCCAEDProgramsince2008:increasepublic awareness,promotelaypersontraininginBLSand coordinateAEDinstallationinsuitablelocation ResuscitationCouncilofHongKongestablishedin May2012(Titleofthe1st 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? 1st Link:earlyaccessbybystander:4.4 2nd Link:earlyCPRbybystander:3.7 3rd Link:defibrillationin<8min:3.4 4th Link:Advancedlifesupport:1.1

BLSClip

BLS
Push hard (Depth >5cm)

Minimally interrupted chest compression

Ensure complete chest recoil

Push fast (Rate >100min)

High Quality CPR

Rotate compressor every 2 mins.

(avoid fatigue)

Compression: Ventilation 30:2

(Vs old 15:2)

Avoid hyperventilation
(ventilate 8 10/min) (decrease survival rate)

Physiologyofcirculationduring standardCPR
C.O.(cardiacoutput):depressed1030% Brain bloodflow:depressed20% Coronary bloodflow:5 15% LowerlimbsandAbdvisceralflow:<5%

Bloodflowgeneratebychestcompressionisso

weakthatanyinterruptioneg.Breathingwill lowerthesurvivalrate
Thus:anyinterruptionofCPRshouldbeminimized

Change of BLS
C A B
3. Checkthepulse 4. Give30chestcompressions(step1to3donein10seconds) 5. Opentheairwayandgive2breaths 6. Resumecompressions

(OldA B C)

1. Checkforresponsivenessandbreathing 2. CallforhelpandgettheAED

(Evidenceshowsthatcompressionsarethecriticalelementin adultresuscitation.IntheABCsequence,compressions areoftendelayed.Layrescuersdifficulttoassessbreathing.)

Circulation 2008; 117:2162-2167 Resuscitation 2008; 78: 119-126

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

BLS
Alternativetechniqueanddevices
Severalalternativetechniqueanddevicesto

conventionalmanualCPR Efficacyreportedinspecificsettings Noalternativetechniqueordevicesinroutine useconsistentlyshowedsuperiorityover conventionalmanualCPR***

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

Sustained PETCO2 >3540mmHg PETCO2 persistently <10mmHg; need to improve CPR quality

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<12hr reperfusiontherapy 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?