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New Practices in ACLS Rapid Fire Jason Persoff, MD Assistant Professor of Hospital Internal Medicine Mayo Clinic Jacksonville Evidence-Based Rapid Fire What new changes to BLS should I be implementing in the hospital setting? What new recommendations related to medications provided during ACLS do I need to know? Should family members be present during a code? ACLS Medications ACLS Medications Antiarrhythmics Increase QTc Increase risk of cardiac arrest Do antiarrhythmics promote survival in IHCA? Bloom: amiodarone improves survival Most others: survival to hospital discharge is lower Bloom et al. Am J Heart 2007 Pollak et al. Can J Card 2006 VanWalraven et al. Ann Emerg Med 1998 ACLS Medications Medications that have shown survival Beta Blockers ACEI Bloom et al. Am J Heart 2007 Vasopressin Pediatrics: survival improved Adults: seen in higher proportion of non-survivors Stiell et al. Lancet 2001 DeMos et al. Crit Care Med 2006 VanWalraven et al. Ann Emerg Med 1998 ACLS Medications Calcium Bicarbonate Higher rates of death in IHCA Atropine Administration occurs higher in non-survivors Higher rates of death in IHCA Magnesium No changes in survival in any subgroup VanWalraven et al. Ann Emerg Med 1998 DeMos et al. Crit Care Med 2006 Thel et al. Lancet 1997 ACLS Medications ACLS Medications Yep V-Fib Nope Shockable Rhythm? PEA Pulseless VT Asystole Have no idea Pressor (Vasopressin or Epi) Antiarrhythmic 360J Mono (Amiodarone) or Shock 150J Biphasic Drug 5 Cycles (150 Compressions) Shock 150J Biphasic Family Presence on a CODE Nursing staff believe families should be present on codes (>75%) Best Kuzin et al. Pediatrics. 2007 Oct;120(4):e895-901 review: Critchell and Marik Am J of Hospice Pall Med 2007 2008: The Revolution Begins Bardy, et al. Home use of automated external defibrillators for sudden cardiac arrest. NEJM 2008; 358: Online only at http://www.nejm.org/. April 1, 2008 Sayre, et al. Hands only (compression-only) CPR. Circulation 2008; 117: Online only at http://circ.ahajournals.org/. April 1, 2008 Peberdy, et al. Survival from in-hospital cardiac arrest during nights and weekends. JAMA 2008; 299: 785-792. Chan, et al. Delayed time to defibrillation after inhospital cardiac arrest. NEJM 2008; 358: 9-17. Epidemiology 88% of inpatient cardiac arrest (IHCA) occurs in patients with DNR orders 12% undergo resuscitation 1.25-3.8 per 1000 admissions Most occur in ICU (45%) Few arrests are unwitnessed (12%) Sandroni et al. Resuscitation 2004. Epidemiology Demographics of 37,782 inpatient cardiac arrests Nadkarni et al., JAMA 2006; 295 Age (y) ± SD (age range) 65.3 ± 15.2 (18-111) Male Gender 57% Caucasian Black Hispanic Other 67% 20% 5% 8% Medical (Cardiac) Medical (Non-Cardiac) Surgical (Cardiac) Surgical (Non-cardiac) Trauma 18% 46% 17% 7% 10% Prognosis Terminology ROSC (Return of spontaneous circulation) SHD (Survival to hospital discharge) NIS (Neurologically intact survival)—CPC 0 or 1 NIS Cerebral Performance Category (CPC) 0 Normal 1 Good 2 Moderate disability (Caffeinated) 3 Major disability 4 Persistent vegetative state, coma 5 Brain death 6 Me post-call Prognosis Pure respiratory events SHD (reference) OR 1.0 Vs. VF/VT Arrest: OR 4.2 (1.4-12.5) Vs. Asystole/PEA Arrest: OR 21.0 (6.2-71.7) Brindley et al. CMAJ 2002. Prognosis Ventricular Fibrillation/Tachycardia ROSC 54-76% SHD 16.5-57% NIS 58-75% PEA/Asystole Arrests ROSC 43-52% SHD 10-20% NIS 61-62% Prognosis Discrepancies Men are twice as likely to have VF than women Herlitz et al. Resuscitation 2002. Women are more likely to survive (OR 1.66, 1.06- 2.62) Herlitz et al. Resuscitation 2001. Blacks have a lower likelihood Ebell et al. J Fam Prac 1995. Blacks had statistically robust Chan et al. NEJM 2008. of SHD delays in defibrillation Prognosis “It’s a good time to die.”—Some action movie 1500 Bad “Golden Hour” time of day: nighttime Survival lowest 2300-0700 Brindley et al. CMAJ 2002. Nocturnal arrest has half the likelihood Herlitz et al. Resuscitation 2002. More likely due to asystole/PEA Peberdy et al. JAMA 2008. of SHD Prognosis Nocturnal IHCA Less likely to have ROSC (44.7% vs. 51.1%) Less likely to survive 24 hours (28.9% vs. 35.4%) Less likely to SHD (14.7% vs. 19.8%) Weekend Commensurate to nocturnal survival Basic Life Support CPR when done perfectly provides only… 1/3 normal cardiac output 10-15% normal cerebral blood flow 1-5% normal cardiac blood flow Sanders et al. 1985. Goals Push hard Pump fast Good recoil How many push ups can you do? Rotate rescuers Basic Life Support In swine… Rapid compressions: 80/min 10% survival at 24 hrs 100/min 100% survival at 24 hrs Yu et al. 2002. Continuous vs. Classic Better coronary perfusion pressures Higher “neurologically normal” function Kern et al. 2002 Basic Life Support Compressions too shallow 62.6% of the time Compressions too slow 71.9% of the time Abella et al. 2005. CPR Good: Survival at 14d: 16% CPR Bad: Survival at 14d: 4% VanHoeyweghen et al. 1993. Basic Life Support Delay in chest compressions = death CPR started < 1 minute after collapse: SHD 34% CPR started 1 minute after collapse: SHD 14% Skrifvars et al. Resuscitation 2006 Code team arrival delay of >2 minutes after arrest: SHD begins to decrease Code team arrival >6 minutes after arrest: SHD 0% Sandroni et al. Resuscitation 2004 Basic Life Support What is the appropriate tidal volume for a patient in cardiopulmonary arrest? 10cc/kg, or roughly 750cc What is the volume of an adult bag-valve-mask? 1.5 liters Designed for 1-handed operation ETT is misplaced 6-14% of the time Katz et al. Ann Int Med 2001. “Iatrogenic hypotension” Over-zealous BVM use due to Desire to correct hypoxia Belief that hyperventilation will correct acid-base derangements Basic Life Support Rate exceeded at least 60.9% of the time in humans In swine models, hyperventilation resulted in… …increased intrathoracic pressure …decreased coronary perfusion pressures …lower survival Aufderheide, et al. 2004. Basic Life Support Phenomenon of auto-PEEP usually referred to patients on a ventilator Basic Life Support Michard F. Anesthesiology 2005 Basic Life Support Current clinical controversy Should April we ventilate at all? 1, 2008 No…compressions only in layperson resuscitation Most animal models show NO BENEFIT to ventilations plus ventilations to compressions only In humans Equivalent SHD in typical and compression-only CPR 1-year NIS similar Basic Life Support Striking the balance No oxygenation without circulation The longer resuscitation is attempted, the lower the oxygen level Threshold appears to be 4 minutes into an arrest Delivery of as little as 2 breaths : 100 compressions after 4 minutes of continuous compressions had better outcomes Sanders et al. Ann Emerg Med 2002. Interesting Only aside…Why don’t people do CPR? 1.4% of bystanders feared disease Conclusions?