new practices in acls rapid fire jason persoff, md assistant professor of hospital internal medicine...
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New Practices in ACLSNew Practices in ACLS
Rapid FireRapid Fire
Jason Persoff, MDJason Persoff, MD
Assistant Professor of Hospital Internal MedicineAssistant Professor of Hospital Internal Medicine
Mayo Clinic JacksonvilleMayo 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
Administration occurs higher in non-survivors Bicarbonate
Higher rates of death in IHCA Atropine
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 MedicationsShockable Rhythm?
Yep
V-Fib
Pulseless VT
Have no idea
Nope
PEA
Asystole
360JMono
150JBiphasic
150JBiphasic
or
5 Cycles
(150 Compressions)
Shock
Drug
Shock
Pressor (Vasopressin or Epi)
Antiarrhythmic (Amiodarone)
Family Presence on a CODE
Nursing staff believe families should be present on codes (>75%)
Kuzin et al. Pediatrics. 2007 Oct;120(4):e895-901
Best 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 in-hospital 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%
CaucasianBlack
HispanicOther
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 of SHD Ebell et al. J Fam Prac 1995.
Blacks had statistically robust delays in defibrillation Chan et al. NEJM 2008.
Prognosis
“It’s a good time to die.”—Some action movie 1500 “Golden Hour”
Bad time of day: nighttime Survival lowest 2300-0700
Brindley et al. CMAJ 2002.
Nocturnal arrest has half the likelihood of SHD Herlitz et al. Resuscitation 2002.
More likely due to asystole/PEA Peberdy et al. JAMA 2008.
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 we ventilate at all?
April 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 aside…Why don’t people do CPR? Only 1.4% of bystanders feared disease
Conclusions?