ACLS GUIDELINES 2021: WHAT’S NEW AND WHY

CAMERON BERG, MD, FAAEM, FACEP

NO RELEVANT DISCLOSURES

CKB ACEP 2021

ACLS 2021

▸ CPR and emergency cardiovascular care (ECC)

▸ 2020 comprehensive updates published 10/2020

▸ Planned to be primary guidelines through 2025

▸ Focused updates may occur (did in 2019)

OHCA UPDATES

CKB ACEP 2021

OHCA

▸ Chest compressions!

▸ Recommend initiating chest compressions for presumed arrest

▸ Community lay rescuer AED programs

▸ Naloxone for BLS when pulse present

▸ Uniform compression/ventilation rate and ratio regardless of age

▸ 100-120 cpm; 5-6 cm depth; full recoil

▸ 10 vpm

Suspected opioid poisoning • Check for responsiveness. • Shout for nearby help. • Activate the emergency response system. • Get naloxone and an AED if available.

Prevent deterioration • Tap and shout. • Reposition. • Consider naloxone. • Continue to observe until

EMS arrives.

Yes NoIs the person breathing

normally?

Start CPR* • Give naloxone. • Use an AED. • Resume CPR until EMS arrives.

*For adult and adolescent victims, responders should perform compressions and rescue breaths for opioid-associated emergencies if they are trained and perform Hands-Only CPR if not trained to perform rescue breaths. For infants and children, CPR should include compressions with rescue breaths.© 2020 American Heart Association

Ongoing assessment of responsiveness and breathing

Go to 1.

1

2

3

4

5

Opioid-Associated Emergency for Lay Responders Algorithm

PRE-HOSPITAL AND ACLS

No, nonshockable

Yes,shockable

No normal breathing, pulse felt

© 2020 American Heart Association

AED arrives.

Check rhythm.Shockable rhythm?

• Give 1 shock. Resume CPR immediately for 2 minutes(until prompted by AED to allow rhythm check).

• Continue until ALS providers take over or victim starts to move.

• Provide rescue breathing, 1 breath every 6 seconds or 10 breaths/min.

• Check pulse every 2 minutes; if no pulse, start CPR.

• If possible opioid overdose,administer naloxone ifavailable per protocol.

• Resume CPR immediately for 2 minutes (until prompted by AED to allow rhythm check).

• Continue until ALS providers take over or victim starts to move.

Start CPR • Perform cycles of 30 compressions

and 2 breaths. • Use AED as soon as it is available.

Monitor until emergency

responders arrive.

Verify scene safety.

• Check for responsiveness. • Shout for nearby help. • Activate emergency response

system via mobile device (if appropriate).

• Get AED and emergency equipment(or send someone to do so).

Look for no breathing or only gasping and check

pulse (simultaneously). Is pulse definitely felt

within 10 seconds?

Normal breathing, pulse felt

No breathing or only gasping,

pulse not felt

By this time in all scenarios, emergency response system or backup is activated, and AED and emergency equipment are retrieved or someone is retrieving them.

Adult Basic Life Su ort Algorithm for Healthcare Providers

© 2020 American Heart Association

CPR Quality

• Push hard (at least 2 inches [5 cm]) and fast (100-120/min) and allow complete chest recoil.

• Minimize interruptions in compressions. • Avoid excessive ventilation. • Change compressor every 2 minutes, or sooner if fatigued. • If no advanced airway, 30:2 compression-ventilation ratio. • Quantitative waveform capnography

– If Petco2 is low or decreasing, reassess CPR quality.

Shock Energy for Defibrillation

• Biphasic: Manufacturer recommendation (eg, initial dose of 120-200 J); if unknown, use maximum available. Second and subsequent doses should be equivalent, and higher doses may be considered.

• Monophasic: 360 J

Drug Therapy

• Epinephrine IV/IO dose: 1 mg every 3-5 minutes • Amiodarone IV/IO dose: First dose: 300 mg bolus. Second

dose: 150 mg. or

• Lidocaine IV/IO dose: First dose: 1-1.5 mg/kg. Second dose: 0.5-0.75 mg/kg.

Advanced Airway

• Endotracheal intubation or supraglottic advanced airway • Waveform capnography or capnometry to confirm and monitor

ET tube placement • Once advanced airway in place, give 1 breath every 6 seconds

(10 breaths/min) with continuous chest compressions

Return of Spontaneous Circulation (ROSC)

• Pulse and blood pressure • Abrupt sustained increase in Petco2 (typically ≥40 mm Hg) • Spontaneous arterial pressure waves with intra-arterial

monitoring

Reversible Causes

• Hypovolemia • Hypoxia • Hydrogen ion (acidosis) • Hypo-/hyperkalemia • Hypothermia

• Tension pneumothorax • Tamponade, cardiac • Toxins • Thrombosis, pulmonary • Thrombosis, coronary

Return of Spontaneous Circulation (ROSC)

Check Rhythm

Drug TherapyIV/IO access

Epinephrine every 3-5 minutesAmiodarone or lidocaine

for refractory VF/pVT

Consider Advanced AirwayQuantitative waveform capnography

Treat Reversible Causes

Start CPR• Give oxygen ttac m it illat

2 minutes

If VF/pVTShock

Post–CardiacArrest Care

Contin

uous

CPR

Continuous CPR

Monitor CPR Quality

Adult Cardiac Arrest Circular Algorithm

CKB ACEP 2021

ADVANCED AIRWAYS

▸ Bag Mask Valve

▸ May not allow adequate ventilation

▸ Does not protect against aspiration

▸ BMV vs endotracheal intubation (ETI) - Jabre et. al.

▸ No difference

▸ Other observational evidence may be confounded

CKB ACEP 2021

ADVANCED AIRWAYS - CONTINUED

▸ Supraglottic airways (SGA)

▸ i-gel trial (RCT with no difference)

▸ laryngeal tube trial (RCT with 21/1000 improvement of neurologically intact discharge)

▸ Recommendations

▸ Any approach is permissible

▸ If advanced airways are used, then quality and reliability of training is paramount

CKB ACEP 2021

ACLS BASICS

▸ Routine drugs not recommended:

▸ Vasopressin

▸ Atropine

▸ Sodium bicarbonate

▸ Calcium

▸ Thrombolytics

▸ Epinephrine (if used) should be used early; maintained 3-5 minute recommendation

▸ Amiodarone and lidocaine may be used for VF/pVT

▸ Confirm all airways with ETCO2; Waveform preferred

CKB ACEP 2021

ETCO2

▸ Low <10mmHg after 20 minutes CPR is highly correlated with negative outcomes

▸ Rapid increase (+10mmHg) suggests ROSC; threshold typically >40mmHg

▸ Steady decrease suggests inadequate CPR

CKB ACEP 2021

VASOPRESSORS

▸ 2019 ILCOR systematic review

▸ Epinephrine (pooled analyses)

▸ RR 3.09 ROSC

▸ RR 2.88 survival to hospital admission (156/1000)

▸ RR 1.44 survival to hospital discharge (10/1000)

▸ no difference in survival to hospital discharge with favorable neurological outcome

▸ PARAMEDIC 2

▸ no difference in survival with favorable or unfavorable neurological outcome at 3 months

CKB ACEP 2021

VASOPRESSORS - CONTINUED

▸ Epinephrine and arrest rhythm

▸ May benefit those with unshockable rhythm

▸ RR 2.56 (6/1000)

▸ Recommendations

▸ Continued with 1mg every 3-5 minutes

▸ High-dose not recommended

▸ Vasopressin may be used (alone or in combination); no clear benefit

CKB ACEP 2021

ECLS

▸ May be considered in certain circumstances

▸ System available

▸ Reversible cause suspected

▸ Good baseline functional status

▸ Short pre-hospital CPR duration

ED ECMO

Oxygenator

Pump

Arterial Blood

Venous Blood

ECPR Circuit

CKB ACEP 2021

ECLS - CONTINUED

▸ ECMO basics

▸ VA

▸ VV

CKB ACEP 2021

ECLS - CONTINUED

▸ ECPR for OHCA

▸ no RCTs in existence

▸ 15 observational studies with > 5 patients

▸ Most required: witnessed arrest, cardiac cause, and age <75

▸ ECPR for INHCA

▸ no RCTs

▸ 7 observational studies

CKB ACEP 2021

ECLS - CONTINUED

▸ Recommendations

▸ Insufficient evidence to recommend routine use

▸ May be considered for selected patients

▸ Trigger should likely be refractory VF/VT

▸ Best outcomes when cannulation begins in first 15 minutes (worse outcomes at 30; very poor at 60)

▸ Most protocols also use expedited coronary angiography

ROSC obtained

Obtain 12-lead ECG

Manage airwayEarly placement of endotracheal tube

Manage respiratory parametersStart 10 breaths/min

Spo2 92%-98%Paco2 35-45 mm Hg

Manage hemodynamic parametersSystolic blood pressure >90 mm Hg Mean arterial pressure >65 mm Hg

Comatose • TTM • Obtain brain CT • EEG monitoring • Other critical care

management

Evaluate and treat rapidly reversible etiologiesInvolve expert consultation for continued management

AwakeOther critical care

management

Follows commands?

© 2020 American Heart Association

Initial Stabilization PhaseResuscitation is ongoing during the post-ROSC phase, and many of these activities can occur concurrently. However, if prioritization is necessary, follow these steps: • Airway management:

Waveform capnography or capnometry to confirm and monitor endotracheal tube placement

• Manage respiratory parameters: Titrate Fio2 for Spo2 92%-98%; start at 10 breaths/min; titrate to Paco2 of 35-45 mm Hg

• Manage hemodynamic parameters: Administer crystalloid and/or vasopressor or inotrope for goal systolic blood pressure >90 mm Hg or mean arterial pressure >65 mm Hg

Continued Management and Additional Emergent ActivitiesThese evaluations should be done concurrently so that decisions on targeted temperature management (TTM) receive high priority as cardiac interventions. • Emergent cardiac intervention:

Early evaluation of 12-lead electrocardiogram (ECG); consider hemodynamics for decision on cardiac intervention

• TTM: If patient is not following commands, start TTM as soon as possible; begin at 32-36°C for 24 hours by using a cooling device with feedback loop

• Other critical care management – Continuously monitor core temperature (esophageal, rectal, bladder)

– Maintain normoxia, normocapnia, euglycemia

– Provide continuous or intermittent electroencephalogram (EEG) monitoring

– Provide lung-protective ventilation

H’s and T’sHypovolemiaHypoxiaHydrogen ion (acidosis) Hypokalemia/hyperkalemia Hypothermia Tension pneumothoraxTamponade, cardiacToxinsThrombosis, pulmonaryThrombosis, coronary

Consider for emergent cardiac intervention if • STEMI present • Unstable cardiogenic shock • Mechanical circulatory support required

Initial Stabilization

Phase

ACLS Healthcare ProviderPost–Cardiac Arrest Care Algorithm

Continued Management

and Additional Emergent Activities

YesNo

CKB ACEP 2021

POST-ARREST MANAGEMENT

▸ Coronary angiography should be emergently performed if post-arrest STE on ECG

▸ Targeted temperature management should be administered to all OHCA survivors who remain comatose

▸ temperature 32-36

▸ duration 24hrs

▸ No prognostication before 72hrs

PRACTICAL CONSIDERATIONS

CKB ACEP 2021

US

▸ Use to identify treatable conditions

▸ hypovolemia

▸ pneumothorax

▸ PE

▸ tamponade

▸ Use to guide or terminate resuscitationREBEL EM

REBEL EM

REBEL EM

REBEL EM

REBEL EM

CKB ACEP 2021

PEARLS - BEYOND ACLS

▸ Pre-charge defibrillator

▸ Use US to confirm PEA

▸ Be systematic with PEA

▸ Dose epinephrine based on BP

▸ DBP 35mmHg

▸ Optimize CPP

▸ REBOA

▸ Vasodilator therapy intra-arrest

QUESTIONS? CAMERON.BERG@GMAIL.COM