ACLS Guidelines 2015

Wanda Rivera Bou MD, FAAEM, FACEP

Assistant Professor
Department of Emergency Medicine
University of Puerto Rico School of Medicine
AHA - ACLS National Faculty
 Disclosure Information
Wanda Rivera Bou, MD

■ I have no financial relationships with drug or

device manufacturing companies
Objectives: Will discuss

n Identify the ACLS 2015 science updates

n Describe the rationale for the science

updates

n Therapeutic interventions
International Liaison Committee on
Resuscitation
Highlights of the 2015 AHA Guidelines Update for CPR and ECC
New AHA Adult Chains of Survival

IN-HOSPITAL
(note new Surveillance
and Prevention link)

OUT OF HOSPITAL
Including EMS
Adult BLS and CPR Quality

n There is continued emphasis on the

characteristics of high-quality CPR:

l compressing the chest at an adequate rate and depth

l allowing complete chest recoil after each compression
l minimizing interruptions in compressions
l avoiding excessive ventilation
 Chest Compression Rate
n It is reasonable to perform compressions at a
rate of 100-120/min Metronome
ü Observational study
ü Dec, 2005 – May, 2007
ü Sharp decline in survival
with rate > 140/min

Idris A.H et al, Circulation. 2012;125:3004-3012

Rapid Compression Rate can
Compromise Depth

Idris et al, Critical Care Medicine, 2015:43 (4): 840

 Chest Compression Depth
n Chest compression to at least 2 inches (5 cm),
avoiding chest compression depths > 2.4
inches (6 cm)
Small study: more injuries with
compressions greater than 2.4
inches (6cm).
(Hellevuo et al, Resuscitation, 2013)

• Difficult to judge depth

without devices

• Rescuers typically don’t

“push hard” enough

Stiell I.G et al, Circulation. 2014;130:1962-1970

BLS for
HCP

Highlights of the 2015 AHA Guidelines Update for CPR and ECC
For BLS and ACLS algorithms, please referred to
http://eccguidelines.heart.org
Bystander CPR
Early CPR Increases Survival
Adult BLS and CPR Quality

n Minimizing interruptions with a goal of chest

compression fraction of at least 60%

n CCF = It is the percentage of time in which

chest compressions are done by rescuers
during a cardiac arrest

n Fewer pauses in CPR increase the chances of

surviving a cardiac arrest (less than 10 sec)
Ventilation During CPR with an
Advanced Airway

n It would be reasonable to deliver 1 breath

every 6 sec (10 breath/min)
ACLS Summary of Key Issues (New)
n Vasopressin and Epinephrine
n ETCO2 for Prediction of Fail Resuscitation
n Steroids (ICHA and OCHA)
n B-Adrenergic Blocking Drugs
n Lidocaine
n PCI
n ECMO
n Targeted Temperature Management
Vasopressin and Epinephrine

n Vasopressin was removed for simplicity

n No benefit of vasopressin over epinephrine

n Epinephrine - timing of administration

l It is reasonable to administer as soon as possible
after the onset of cardiac arrest due to an initial
nonshockable rhythm (PEA/Asystole)
ETCO2

n Low ETCO2 (< 10 mmHg) in intubated pts

after 20 mins of CPR is associated with a low
likelihood of resuscitation (shouldn’t be used
in isolation)
Steroids

n There are no data to recommend for or

against the routine use alone for IHCA (Class
IIb, LOE C-LD)

n Uncertain benefit for OHCA

Post-Cardiac Arrest Drug Therapy:
New
n B-blocker
l There is inadequate evidence to support routine use
after cardiac arrest

n Lidocaine
l There is inadequate evidence to support the routine
use after cardiac arrest
PCI
n Should be performed emergently for OHCA pts
with suspected cardiac etiology and STEMI
(Class I, LOE B-NR)

n Reasonable for select pts after OHCA with

suspected cardiac etiology but w/o STE on ECG
(Class II a, LOE B-NR)

n Reasonable in post-cardiac arrest pts for whom

angiography is indicated regardless of whether
is comatose or awake (Class II a, LOE C-LD)
ECMO

n May be considered for select pts, in settings

where it can be rapidly implemented (Class
IIb, LOE C-LD)
Targeted Temperature
Management
n All comatose pts with ROSC should have a
TTM for at least 24 hrs
l TT between 32ºC-36ºC, maintained constantly
n Continuing TM beyond 24 hrs
l Is reasonable in comatose pts to actively prevent
fever
n Out of Hospital Cooling
l Not recommended
Nielsen N. et al, N Engl J Med. 2013;369:2197-2206
PROGNOSTICATION for poor
outcome USING CLINICAL EXAM

n The earliest time for prognostication in pts

treated with TTM, may be 72 hrs after return
of normothermia (Class II b, LOE C-EO)

n The earliest time for prognostication in pts not

treated with TTM is 72 hrs after cardiac arrest
(Class I, LOE B-NR)
Updated Recommendations:
Special Circumstances
n Naloxone administration in combination with
BLS care for opioid-associated life-threatening
emergencies

n Intravenous lipid emulsion considered for

treatment of local anesthetic systemic toxicity

n Refined recommendations regarding uterine

displacement for CPR during pregnancy
Take-Home Messages

n Lay provider care saves lives

n Defibrillation as early as possible
n Medications have modest benefit
n Advanced Airway is a lower priority early in
cardiogenic arrest
l If performed, don’t interrupt more important
interventions (compressions, defibrillation)
Take-Home Messages

n Post-resuscitation care is a key component of

management
l Targeted Temperature Management
l Coronary Reperfusion

n Do not forget your basic critical care skills

wandabou@me.com