Transcript Resuscitation guidelines 2010 & ACLS Updates

Resuscitation guidelines 2010
& ACLS Updates
Delivered By
The American Heart Association
Presented By
Dr Hesham Mohamed Allam
INTRODUCTION
Editorial
Resuscitation guidelines 2010:
a scientific consensus
Anaesthesia, 2010, 65, pages 1163–
1172

Sudden cardiac death is a major killer of adults, and coronary heart disease –
which kills as many as 99 000 per annum in the UK [1] – is the underlying
cause in the majority of those over 40 years of age.

In some countries, survival for patients who collapse in ventricular fibrillation
(VF) is as high as 35% in some countries, in the UK this is not the case.

from the beginning of 2008, more than 300 worksheets were completed,
collating and evaluating all available published scientific papers on the
questions posed.

In February 2010, the worksheets were reviewed and consensus positions
were agreed.

Thus major differences were eliminated, which leaded to ease in
implementation and avoided fatigue and confusion within the health care
providers’ community.

In the 2005 guidelines, the focus was on cardiac compressions
and simplification of approach, to allow more effective teaching
in clinical practice.

Change in the new guidelines is that there is now a chapter on
pre-hospital cardiac arrest, recognising:
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The different aetiologies of these events
The unique challenges they pose for both the public witness and the
healthcare community
The high impact this phase has on subsequent patient outcome.
Key questions before the 2010 guidelines
included whether:
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Compression only CPR is the best choice for laybystanders.
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Pre-hospital intubation should be phased out in favour of supraglottic
airway devices.

Should be compressions before defibrillation in non-witnessed
resuscitation attempts.
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Therapeutic hypothermia is now established for patients with VF and
ventricular tachycardia (VT), but should it be extended to non-shockable
rhythms?
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What is the real place of drugs in resuscitation?
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Can we more quickly predict those who are likely to survive?
Changes in 2010 Update
THE QUALITY OF CHEST
COMPRESSION

In basic life support, compression depth has been increased to
between 5 & 6 cm.

The use of feedback technology( separate units or integrated
into defibrillators) promoted, to assist in the delivery of highquality compressions.

Previous studies on both suggested that to achieve ROSC, CPP
of over 15 mmHg during chest compressions are required and
that the depth previously recommended of 4–5 cm for chest
compressions was inadequate.
Minimizing of disruption in the
compression sequence

Defibrillation should take a maximum period of five seconds,
with charging during chest compressions.

For tracheal intubation, ten seconds’ hands-off time for the
passage of the tube is the onlypoint at which compressions are
paused.

Pulse checks are only undertaken where there are signs
suggestive of ROSC.
AIRWAY MANAGEMENT

The emphasis on tracheal intubation continues to decrease in
favour of supraglottic airway devices due to:
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Concerns about complications of intubation.
Long pauses in compressions without basic airway management and
unrecognised oesophageal intubation, especially in those who perform the
skill infrequently.
Intubation for cardiac arrest patients in an emergency is challenging
Delaying intubation
until after ROSC is suggested as a possible
Approach.
Many studies have shown that use of a supraglottic device in the
cardiac arrest situation is quick and easy without significant
change in the outcome.

Professionals are advised to use both primary clinical and
secondary adjunct confirmation techniques to confirm the
correct placement of tracheal tubes.

However, with the low output produced by chest compressions,
digital display of end-tidal CO2 alone is not very reliable, and the
presence of CO2 is more positive than its absence.

The current guidelines for all age groups recommend that it
should be used as enabling confirmation of tracheal tube
placement, it also indicates good quality chest compressions and
is an early indicator of ROSC.
USE & TIMING OF DRUGS
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The use and timing of drugs have been simplified.
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Adrenaline is given after the third shock at the same time as
amiodarone, easier to remember than in separate cycles.
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Atropine, long given for asystole and slow PEA, is discontinued,
it remains for peri-arrest management.
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The tracheal route of drug administration is not recommended
except in neonates following the widespread introductionof
intraosseous devices.
FIBRINOLYSIS?
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Fibrinolysis is recommended for patients presenting
with a likely diagnosis of pulmonary embolus, as well as
other likely thrombotic aetiologies.
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This is based on expert consensus, although the study
was curtailed due to lack of a benefit trend in all-comer
cardiac arrest patients.
POST-RESUSCITATIO CARE
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Outcomes for out of-hospital cardiac arrest survivors are extremely variable between
institutions, due to variable approaches and different standards of care.
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Individual elements of care include:
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Early Re-perfusion therapy ( use of angioplasty and primary reperfusion in comatose post-cardiac
arrest patients without proven ST-elevation myocardial infarction will be controversial to some, andnot all
hospitals will be able to deliver it ).
Wider use of Therapeutic Hypothermia ( was incorporated into the 2005 guidelines for
comatose adult survivors of out-of-hospital cardiac arrest presenting in either VF or VT ).
Titrated Oxygen therapy ( Oxygen therapy is increasingly recognised as being potentially harmful,
early titration of inspired oxygen against arterial gases or oxygen saturation is recommended especially in
neonatal care ).
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Moderate Glucose control ( Tight glucose control was thought to be beneficial, but, may
lead to masked hypoglycaemic episodes and therefore the guidance on this has been relaxed
).
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Capnography is recommended as is the use of therapeutic hypothermia for babies
with encephalopathy.
GUIDELINES FOR PAEDIATRIC
PATIENTS
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Diminution in the importance of a pulse check by healthcare
providers in confirming cardiac arrest.
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Lay bystanders are encouraged to perform compression-only
CPR, whereas for trained rescuers, the Compression:Ventilation
ratio of 3:1 remains.
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Use of automated external defibrillator in infants is suggested.
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Use of drugs is brought in line with the adult algorithm.
DISADVATAGES
1.
Step-changes between iterations of guidelines inevitably mean
that more than one change to ‘standard CPR’ occurs.
2.
Some trials were undertaken where multiple variables acted as
confounders; consequently, clear answers to important
questions could not always be gained.
3.
Major limitation in the timeframe for the process. The
worksheets were compiled over the period 2008 to mid-2009
and therefore important papers published recently will not
have been included.
2010 American Heart Association Guidelines
for Cardiopulmonary
Resuscitation and Emergency Cardiovascular
Care
Airway Control
and Ventilation
Ventilation and Oxygen Administration
During CPR

During CPR, oxygen delivery to the heart and brain is limited by
blood flow rather than by arterial oxygen content.
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Rescue breaths are less important than chest compressions
during the first few minutes of resuscitation and could lead to
interruption in chest compressions.
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Increase in intra-thoracic pressure that accompanies positive
pressure ventilation decreases CPR efficacy.
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Advanced airway placement in cardiac arrest should not delay
initial CPR and defibrillation for VF cardiac arrest
Oxygen Administration During CPR
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It is unknown whether 100% inspired oxygen is beneficial or whether titrated
oxygen is better.
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Prolonged exposure to 100% inspired oxygen has potential toxicity.
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Passive oxygen delivery via mask with an opened airway during the first 6
minutes of CPR provided by (EMS) resulted in improved survival.
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In theory, as ventilation requirements are lower during cardiac arrest, oxygen
supplied by passive delivery is likely to be sufficient for several minutes after
onset of cardiac arrest with a patent upper airway.
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All healthcare providers should be able to provide ventilation with a bagmask device during CPR or when the patient demonstrates cardiorespiratory
compromise.
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Airway control with an advanced airway, which may include an ETTor a
supraglottic airway device, is a fundamental ACLS skill.
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Prolonged interruptions in chest compressions should be avoided during
advanced airway placement.
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All providers should be able to confirm and monitor correct placement of
advanced airways.
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Training, frequency of use, and monitoring of success and complications
are more important than the choice of a specific advanced airway device for
use during CPR.
Management of Cardiac Arrest
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Cardiac arrest can be caused by 4 rhythms: ventricular fibrillation (VF),
pulseless ventricular tachycardia (VT), pulseless electric activity (PEA), and
asystole.
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VF represents disorganized electric activity, whereas pulseless VT represents
organized electric activity of the ventricular myocardium. Neither generates
significant forward blood flow.
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PEA encompasses a heterogeneous group of organized electric rhythms
associated with either absence of mechanical ventricular activity or
mechanical ventricular activity that is insufficient to generate a clinically
detectable pulse.
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Asystole ( ventricular asystole ) represents absence of detectable ventricular
electric activity with or without atrial electric activity.
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For VF/pulseless VT, attempted defibrillation within minutes of collapse. For
victims of witnessed VF arrest, early CPR and rapid defibrillation can
significantly increase the chance for survival to hospital discharge.
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Other ACLS therapies such as some medications and advanced airways,
although associated with an increased rate of ROSC, have not been shown to
increase the rate of survival to hospital discharge.
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Combination of higher quality CPR and post arrest interventions such as
therapeutic hypothermia and early percutaneous coronary intervention (PCI),
doesn’t necessarily improves the outcome.
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Periodic pauses in CPR should be as brief as possible and only as necessary to
assess rhythm, shock VF/VT, perform a pulse check when an organized
rhythm is detected, or place an advanced airway.
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Monitoring and optimizing quality of CPR is encouraged and includes:
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Optimizing chest compression rate and depth, adequacy of relaxation, and
minimization of pauses.
Monitoring partial pressure of end-tidal CO2 [PETCO2], arterial pressure
during the relaxation phase of chest compressions, or [ScvO2] when feasible.
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In the absence of an advanced airway, a synchronized compression–
ventilation ratio of 30:2 is recommended at a compression rate of at least 100
per minute.
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After placement of an advanced airway, the provider performing chest
compressions should deliver at least 100 compressions per minute without
pauses for ventilation.
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The provider delivering ventilations should give 1 breath every 6 to 8 seconds
(8 to 10 breaths per minute) and should avoid delivering an excessive number
of ventilations.
ADULT CARDIAC ARREST
ALGORITHM
MANAGEMENT OF SYMPTOMATIC
BRADYCARDIA & TACHYCARDIA
Preface
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The goal of therapy for bradycardia or tachycardia is to rapidly
identify and treat patients who are hemodynamically unstable.
Drugs or,
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Drugs or, pacing may be used to control unstable or
symptomatic bradycardia.
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Cardioversion or drugs or both may be used to control unstable
or symptomatic tachycardia.
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ACLS providers should closely monitor stable patients pending
expert consultation and should be prepared to aggressively
treat those with evidence of decompensation.
BRADYARRHYTHMIA
TACHYARRHYTHMIA
CARDIOVERSION
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