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Todd M. Larabee, MD Department of Emergency Medicine University of Colorado Denver SOM

Todd M. Larabee, MD Department of Emergency Medicine University of Colorado Denver SOM

Todd M. Larabee, MD Department of Emergency Medicine University of Colorado Denver SOM
Todd M. Larabee, MD Department of Emergency Medicine University of Colorado Denver SOM
Todd M. Larabee, MD Department of Emergency Medicine University of Colorado Denver SOM
Todd M. Larabee, MD Department of Emergency Medicine University of Colorado Denver SOM
 Issues after 2005 Guideline changes  ILCOR Process  Highlights of the 2010 Guidelines

Issues after 2005 Guideline changes

ILCOR Process

Highlights of the 2010 Guidelines

BLS

ACLS

PALS

Summary

2005 Guideline changes  ILCOR Process  Highlights of the 2010 Guidelines ◦ BLS ◦ ACLS
2005 Guideline changes  ILCOR Process  Highlights of the 2010 Guidelines ◦ BLS ◦ ACLS
2005 Guideline changes  ILCOR Process  Highlights of the 2010 Guidelines ◦ BLS ◦ ACLS
2005 Guideline changes  ILCOR Process  Highlights of the 2010 Guidelines ◦ BLS ◦ ACLS
 Biggest changes in 2005 were 30:2 compression ration and the change in defibrillation sequence

Biggest changes in 2005 were 30:2

compression ration and the change in

defibrillation sequence

Growing emphasis on high-quality CPR

Implementation of the 2005 guidelines did

improve outcomes

Implementing new guidelines can take 18

months-4 years

Implementation of the 2005 guidelines did improve outcomes  Implementing new guidelines can take 18 months-4
Implementation of the 2005 guidelines did improve outcomes  Implementing new guidelines can take 18 months-4
Implementation of the 2005 guidelines did improve outcomes  Implementing new guidelines can take 18 months-4
Implementation of the 2005 guidelines did improve outcomes  Implementing new guidelines can take 18 months-4
 Since 2005, there’s been an emphasis to simplify CPR recommendations  Stress high-quality CPR

Since 2005, there’s been an emphasis to

simplify CPR recommendations

Stress high-quality CPR

Stress utility/importance of bystander CPR

Need to remove barriers to performance of

bystander CPR

De-emphasis on devices and drugs

Importance of post-cardiac arrest care

Importance of continuing education and training

on devices and drugs  Importance of post-cardiac arrest care  Importance of continuing education and
on devices and drugs  Importance of post-cardiac arrest care  Importance of continuing education and
 Objectives: ◦ Provide a forum for discussion and coordination of all aspects of cardiopulmonary

Objectives:

Provide a forum for discussion and coordination of

all aspects of cardiopulmonary and cerebral

resuscitation worldwide.

Foster scientific research in areas of resuscitation where there is a lack of data or controversy exists.

Disseminate information on training and education

in resuscitation.

Provide a mechanism for collecting, reviewing and sharing international resuscitation data.

Produce statements on specific issues related to

resuscitation that reflect international consensus.

data. ◦ Produce statements on specific issues related to resuscitation that reflect international consensus.
data. ◦ Produce statements on specific issues related to resuscitation that reflect international consensus.
data. ◦ Produce statements on specific issues related to resuscitation that reflect international consensus.
data. ◦ Produce statements on specific issues related to resuscitation that reflect international consensus.
Resuscitation Council of Asia (current members Japan, Korea, Singapore, Taiwan)
Resuscitation Council of Asia (current members Japan, Korea, Singapore, Taiwan)
Resuscitation Council of Asia (current members Japan, Korea, Singapore, Taiwan)
Resuscitation Council of Asia (current members Japan, Korea, Singapore, Taiwan)
Resuscitation Council of Asia (current members Japan, Korea, Singapore, Taiwan)
Resuscitation Council of Asia (current members Japan, Korea, Singapore, Taiwan)
Resuscitation Council of Asia (current members Japan, Korea, Singapore, Taiwan)
Resuscitation Council of Asia (current members Japan, Korea, Singapore, Taiwan)
Resuscitation Council of Asia (current members Japan, Korea, Singapore, Taiwan)
Resuscitation Council of Asia (current members Japan, Korea, Singapore, Taiwan)
Resuscitation Council of Asia (current members Japan, Korea, Singapore, Taiwan)

Resuscitation Council of Asia (current members Japan, Korea, Singapore, Taiwan)

 Task Forces generate worksheets/PICO questions  411 scientific evidence reviews on 277 topics related

Task Forces generate worksheets/PICO

questions

411 scientific evidence reviews on 277 topics related to resuscitation and ECC

356 “experts” from 29 countries

Debates/discussions via telephone/in- person/webinars

Creates the most current and comprehensive review of resuscitation literature ever published

person/webinars  Creates the most current and comprehensive review of resuscitation literature ever published
person/webinars  Creates the most current and comprehensive review of resuscitation literature ever published
person/webinars  Creates the most current and comprehensive review of resuscitation literature ever published
person/webinars  Creates the most current and comprehensive review of resuscitation literature ever published
In adult patients in cardiac arrest (asystole, pulseless electrical activity, pulseless VT and VF) (prehospital

In adult patients in cardiac arrest (asystole,

pulseless electrical activity, pulseless VT and VF) (prehospital [OHCA], in-hospital [IHCA]) (P), does the use of vasopressors

(epinephrine, norepinephrine, others) or

combination of vasopressors (I) compared with not using drugs (or a standard drug

regimen) (C), improve outcomes (eg. ROSC,

survival) (O).

(I) compared with not using drugs (or a standard drug regimen) (C), improve outcomes (eg. ROSC,
(I) compared with not using drugs (or a standard drug regimen) (C), improve outcomes (eg. ROSC,
(I) compared with not using drugs (or a standard drug regimen) (C), improve outcomes (eg. ROSC,
(I) compared with not using drugs (or a standard drug regimen) (C), improve outcomes (eg. ROSC,

Levels of Evidence for Therapeutic Interventions

LOE 1: Randomised Controlled Trials (or meta-analyses of RCTs)

LOE 2: Studies using concurrent controls without true randomisation (eg. “pseudo”-randomised) (or meta-analyses of such studies)

LOE 3: Studies using retrospective controls

LOE 4: Studies without a control group (eg. case series)

LOE 5: Studies not directly related to the specific patient/population (eg. different

patient/population, animal models, mechanical models etc.)

related to the specific patient/population (eg. different patient/population, animal models, mechanical models etc.)

Evidence Supporting Clinical Question

Good

   

(Goetting and Paradis 1991)A-D (Grmec and Mally 2006)A-C

(Gonzalez, Ornato et al. 1989)E (Lindner, Prengel et al. 1996)A-D

 

Fair

 

(Paradis, Martin

 

(Barton and Callaham 1991)A

 

et al. 1991)E

(Matok, Vardi et al. 2007)A-C

Poor

   

(Guyette, Guimond et al. 2004)A,

   

E

(Goetting and Paradis 1989)A

 

1

2

3

4

5

 

Level of evidence

A = Return of spontaneous circulation C = Survival to hospital discharge

B = Survival of event

D = Intact neurological survival

hospital discharge B = Survival of event D = Intact neurological survival E = Other endpoint
hospital discharge B = Survival of event D = Intact neurological survival E = Other endpoint
hospital discharge B = Survival of event D = Intact neurological survival E = Other endpoint
hospital discharge B = Survival of event D = Intact neurological survival E = Other endpoint

E = Other endpoint Italics = Animal studies

Neutral evidence table

Neutral evidence table Good Fair Poor (Aung and Htay 2005)A-D (Brown, Martin et al. 1992)A-D (Callaway,

Good

Fair

Poor

(Aung and Htay 2005)A-D (Brown, Martin et al. 1992)A-D (Callaway, Hostler et al. 2006)A-D (Choux, Gueugniaud et al. 1995)A-D (Gueugniaud, David et al. 2008)A-D (Gueugniaud, Mols et al. 1998)A-D (Lindner, Dirks et al. 1997)A-D (Lindner, Ahnefeld et al. 1991)A-C (Lipman, Wilson et al. 1993) A,B,E

(Olson, Thakur et al. 1989)A-C (Olasveengen, Sunde et al. 2009)A-D (Callaham, Madsen et al. 1992)A-D (Lindner, Ahnefeld et al. 1991) A-C (Patrick, Freedman et al. 1995)A-D (Perondi, Reis et al. 2004)A-C (Sherman, Munger et al. 1997)A-C (Stiell, Hebert et al. 1992)A-D (Stiell, Hebert et al. 2001)A-E

(Turner, Parsons et al. 1988)A-D

(Wenzel, Krismer et al. 2004)A-D

Parsons et al. 1988)A-D (Wenzel, Krismer et al. 2004)A-D (Patterson, Boenning et al. 2005)A-D (Silfvast, Saarnivaara

(Patterson, Boenning et al. 2005)A-D (Silfvast, Saarnivaara et al. 1985)A (Vandycke and Martens 2000)A-D (Takeo, Kosaku et al. 2009)A-D

(Woodhouse, Cox et al. 1995)A-C

(Herlitz, Ekstrom et al. 1995)A-C

(Morris, Dereczyk et al. 1997) E

(Gonzalez, Ornato et al.

1988)E

(Carvolth and Hamilton

1996)A-C

(Carpenter and Stenmark

1997)A-D

(Dieckmann and Vardis

1995)A-D

(Mally, Jelatancev et al.

2007)A-C, E

(Callaham, Barton et al.

1991)B-E

(Ong, Tan et al. 2007)A-D

1

2

3

4

5

Level of evidence

A = ROSC

C = Survival to hospital discharge

E = Other endpoint

B = Survival of event D = Intact neurological survival

Opposing evidence table

Good

Fair

Poor

(Rivers, Wortsman et al. 1994)A, B, E

(Behringer, Kittler et al.

1998)A,D

(Chang, Ma et al.

2007)E

(Duncan, Meaney et al.

2009)A-E

1

2

3

4

5

Level of evidence

A = Return of spontaneous circulation B = Survival of event

C = Survival to hospital discharge D = Intact neurological survival

E = Other endpoint Italics = Animal studies

event C = Survival to hospital discharge D = Intact neurological survival E = Other endpoint
event C = Survival to hospital discharge D = Intact neurological survival E = Other endpoint
event C = Survival to hospital discharge D = Intact neurological survival E = Other endpoint
event C = Survival to hospital discharge D = Intact neurological survival E = Other endpoint
 “Look, listen, feel” removed from algorithm ◦ delays  Early activation of EMS 

“Look, listen, feel” removed from algorithm

delays

Early activation of EMS

Compression-only CPR for the untrained lay- rescuer

High-quality CPR

Minimize interruptions

Deemphasis on pulse checks during CPR

the untrained lay- rescuer  High-quality CPR  Minimize interruptions  Deemphasis on pulse checks during
the untrained lay- rescuer  High-quality CPR  Minimize interruptions  Deemphasis on pulse checks during
the untrained lay- rescuer  High-quality CPR  Minimize interruptions  Deemphasis on pulse checks during
the untrained lay- rescuer  High-quality CPR  Minimize interruptions  Deemphasis on pulse checks during
 C-A-B not A-B-C ◦ Most arrest are adult; most survivors are VF/VT ◦ Emphasis

C-A-B not A-B-C

Most arrest are adult; most survivors are

VF/VT

Emphasis on performing high-quality CPR

and early defibrillation

Delay in “C” when attempting “A”

May remove barriers to bystander CPR

CPR and early defibrillation ◦ Delay in “C” when attempting “A” ◦ May remove barriers to
CPR and early defibrillation ◦ Delay in “C” when attempting “A” ◦ May remove barriers to
CPR and early defibrillation ◦ Delay in “C” when attempting “A” ◦ May remove barriers to
CPR and early defibrillation ◦ Delay in “C” when attempting “A” ◦ May remove barriers to
 Untrained lay-person ◦ Hands-only CPR ◦ Continue until AED/trained personnel available  Trained lay-person

Untrained lay-person

Hands-only CPR

Continue until AED/trained personnel available

Trained lay-person

Hands-only CPR

If willing to perform ventilations with 30:2 ratio

Continue until AED/trained personnel available

Healthcare Provider

CPR including ventilations with 30:2 ratio

Can tailor sequence of interventions based on cause of arrest

◦ CPR including ventilations with 30:2 ratio ◦ Can tailor sequence of interventions based on cause
◦ CPR including ventilations with 30:2 ratio ◦ Can tailor sequence of interventions based on cause
◦ CPR including ventilations with 30:2 ratio ◦ Can tailor sequence of interventions based on cause
◦ CPR including ventilations with 30:2 ratio ◦ Can tailor sequence of interventions based on cause
 CPR Techniques and Devices ◦ No adjunct has been shown to be superior to

CPR Techniques and Devices

No adjunct has been shown to be superior to

manual CPR

ITD (ResQPOD) improved ROSC and short-term survival

Load-band CPR (Autopulse) with no change in 4-

hr survival and worsened neurologic outcomes

Mechanical piston devices with varying degrees of success

All require additional equipment and training;

training needs to be ongoing

More research needed

of success ◦ All require additional equipment and training; training needs to be ongoing ◦ More
of success ◦ All require additional equipment and training; training needs to be ongoing ◦ More
of success ◦ All require additional equipment and training; training needs to be ongoing ◦ More
of success ◦ All require additional equipment and training; training needs to be ongoing ◦ More
 Electrical Therapy ◦ Emphasis on AEDs and addition of AEDs to enhance the chain

Electrical Therapy

Emphasis on AEDs and addition of AEDs to

enhance the chain of survival

CPR before defibrillation remains unclear

Continuing with 1-shock protocol with

minimizing CPR interruptions

◦ CPR before defibrillation remains unclear ◦ Continuing with 1-shock protocol with minimizing CPR interruptions
◦ CPR before defibrillation remains unclear ◦ Continuing with 1-shock protocol with minimizing CPR interruptions
◦ CPR before defibrillation remains unclear ◦ Continuing with 1-shock protocol with minimizing CPR interruptions
◦ CPR before defibrillation remains unclear ◦ Continuing with 1-shock protocol with minimizing CPR interruptions
 Successful ACLS is predicated on good BLS ◦ High-quality CPR with minimal interruptions ◦

Successful ACLS is predicated on good BLS

High-quality CPR with minimal interruptions

Early defibrillation

Fifth link in “Chain of Survival”: Post- Cardiac Arrest Care

Multidisciplinary care from BLS to discharge for good neurologic outcome

Qualitative waveform capnography

Care ◦ Multidisciplinary care from BLS to discharge for good neurologic outcome  Qualitative waveform capnography
Care ◦ Multidisciplinary care from BLS to discharge for good neurologic outcome  Qualitative waveform capnography
Care ◦ Multidisciplinary care from BLS to discharge for good neurologic outcome  Qualitative waveform capnography
Care ◦ Multidisciplinary care from BLS to discharge for good neurologic outcome  Qualitative waveform capnography
 Airway Management: ◦ Qualitative waveform capnography recommended ◦ Suppraglottic airway devices are supported

Airway Management:

Qualitative waveform capnography recommended

Suppraglottic airway devices are supported as airway alternative

Cricoid pressure is no longer recommended

Symptomatic Dysrrhythmias

Adenosine is safe for diagnostics in stable, undifferentiated wide-complex monomorphic

tachycardia

For stable or unstable bradycardia, IV chronotropic agents recommended as equally effective as external pacing

ACLS Cardiac Arrest Circular Algorithm Neumar, R. W. et al. Circulation 2010;122:S729 - S767 Copyright

ACLS Cardiac Arrest Circular Algorithm

ACLS Cardiac Arrest Circular Algorithm Neumar, R. W. et al. Circulation 2010;122:S729 - S767 Copyright ©2010

Neumar, R. W. et al. Circulation 2010;122:S729 - S767

Circular Algorithm Neumar, R. W. et al. Circulation 2010;122:S729 - S767 Copyright ©2010 American Heart Association

Copyright ©2010 American Heart Association

Circular Algorithm Neumar, R. W. et al. Circulation 2010;122:S729 - S767 Copyright ©2010 American Heart Association
Copyright ©2010 American Heart Association ACLS Cardiac Arrest Algorithm Neumar, R. W. et al. Circulation

Copyright ©2010 American Heart Association

ACLS Cardiac Arrest Algorithm

©2010 American Heart Association ACLS Cardiac Arrest Algorithm Neumar, R. W. et al. Circulation 2010;122:S729 -

Neumar, R. W. et al. Circulation 2010;122:S729 - S767

©2010 American Heart Association ACLS Cardiac Arrest Algorithm Neumar, R. W. et al. Circulation 2010;122:S729 -
 Notice on the charts: ◦ Vascular access, drug delivery, advanced airway placement are recommended

Notice on the charts:

Vascular access, drug delivery, advanced airway

placement are recommended but should not

interrupt CPR

Atropine no longer recommended for PEA/asystole

Real-time monitoring of CPR quality

Mechanical parameters

Physiologic parameters

Post-arrest care now a component of the algorithm

CPR quality  Mechanical parameters  Physiologic parameters ◦ Post-arrest care now a component of the
CPR quality  Mechanical parameters  Physiologic parameters ◦ Post-arrest care now a component of the
CPR quality  Mechanical parameters  Physiologic parameters ◦ Post-arrest care now a component of the
CPR quality  Mechanical parameters  Physiologic parameters ◦ Post-arrest care now a component of the
 Post Cardiac-Arrest Care ◦ Multidisciplinary team ◦ Structured, integrated, bundled system of care 

Post Cardiac-Arrest Care

Multidisciplinary team

Structured, integrated, bundled system of care

Key Objectives

Optimize cardiopulmonary function and vital organ perfusion after ROSC

Transport to an appropriate critical care unit with

comprehensive post-cardiac arrest care system

Identify/intervention for ACS

Temperature control for improving neurologic

outcomes

Prevention and treatment of multi-organ dysfunction

ACS ◦ Temperature control for improving neurologic outcomes ◦ Prevention and treatment of multi-organ dysfunction
ACS ◦ Temperature control for improving neurologic outcomes ◦ Prevention and treatment of multi-organ dysfunction
ACS ◦ Temperature control for improving neurologic outcomes ◦ Prevention and treatment of multi-organ dysfunction
ACS ◦ Temperature control for improving neurologic outcomes ◦ Prevention and treatment of multi-organ dysfunction
 Emphasis on asphyxial arrest combined with chest compressions  Compression-only CPR for bystanders unwilling

Emphasis on asphyxial arrest combined with chest compressions

Compression-only CPR for bystanders unwilling or unable to perform ventilations C-A-B for ease of teaching (A-B-C continues in Neonatal Resuscitation)

High-quality CPR

perform ventilations  C-A-B for ease of teaching (A-B-C continues in Neonatal Resuscitation)  High-quality CPR
perform ventilations  C-A-B for ease of teaching (A-B-C continues in Neonatal Resuscitation)  High-quality CPR
perform ventilations  C-A-B for ease of teaching (A-B-C continues in Neonatal Resuscitation)  High-quality CPR
perform ventilations  C-A-B for ease of teaching (A-B-C continues in Neonatal Resuscitation)  High-quality CPR
 Deemphasis on pulse checks  Updated formula for cuffed tubes in infants and young

Deemphasis on pulse checks Updated formula for cuffed tubes in infants and young children

Uncuffed:

Cuffed:

4 + (age/4) if > 2yr

3.5 up to 1 yr, 4.0 if >1yr

3.5 + (age/4) if >2yr 3.0 up to 1yr, 3.5 if >1yr

Safety and value of cricoid pressure questioned; can discontinue if impedes airway

3.0 up to 1yr, 3.5 if >1yr  Safety and value of cricoid pressure questioned; can
3.0 up to 1yr, 3.5 if >1yr  Safety and value of cricoid pressure questioned; can
3.0 up to 1yr, 3.5 if >1yr  Safety and value of cricoid pressure questioned; can
3.0 up to 1yr, 3.5 if >1yr  Safety and value of cricoid pressure questioned; can
 Capnography recommended  Optimal defibrillation energy dose uncertain- recommending 2-4J/kg (either waveform)

Capnography recommended Optimal defibrillation energy dose uncertain- recommending 2-4J/kg (either waveform)

Concerns of hyperoxemia after ROSC

defibrillation energy dose uncertain- recommending 2-4J/kg (either waveform)  Concerns of hyperoxemia after ROSC
defibrillation energy dose uncertain- recommending 2-4J/kg (either waveform)  Concerns of hyperoxemia after ROSC
defibrillation energy dose uncertain- recommending 2-4J/kg (either waveform)  Concerns of hyperoxemia after ROSC
defibrillation energy dose uncertain- recommending 2-4J/kg (either waveform)  Concerns of hyperoxemia after ROSC
 Fewer, less dramatic changes than in 2005  Circulation more important than ventilation in

Fewer, less dramatic changes than in 2005

Circulation more important than ventilation in

most instances

C-A-B

Goodbye Atropine

Post resuscitation care and neurologic

outcomes focus

in most instances  C-A-B  Goodbye Atropine   Post resuscitation care and neurologic outcomes
in most instances  C-A-B  Goodbye Atropine   Post resuscitation care and neurologic outcomes
in most instances  C-A-B  Goodbye Atropine   Post resuscitation care and neurologic outcomes
in most instances  C-A-B  Goodbye Atropine   Post resuscitation care and neurologic outcomes
Thanks for listening.

Thanks for listening.

Thanks for listening.
Thanks for listening.
Thanks for listening.
Thanks for listening.