ALS2015 UPDATE

1. Updates in resuscitation
2015 CPR guidelines
Dr Luah Lean Wah
Consultant anaesthesiologist
Penang Hospital

2. Content of lecture
• ILCOR and 2015 CPR guidelines development
process
• Highlights in BLS guideline
• Updates in ALS
• Post cardiac arrest care

3. • American Heart Association (AHA)
• European Resuscitation Council (ERC)
• Heart and Stroke Foundation of Canada (HSFC)
• Australian and New Zealand Committee on Resuscitation
(ANZCOR)
• Resuscitation Council of Southern Africa (RCSA)
• Inter American Heart Foundation (IAHF)
• Resuscitation Council of Asia (RCA)
 Was formed in 1992
 Forum for liaison between principal
resuscitation organizations worldwide
 allow evaluation process by which the
international science and knowledge
relevant to CPR and ECC is identified and
reviewed

4. ILCOR
• every 5 years a new set of treatment
recommendation is released
• The first set of guidelines was released in
2000, then 2005, 2010 and the latest is
released in October of 2015

5. • 15 October 2015

6. 2015 CPR Guidelines Developmental
Process
• 250 evidence reviewers from 39 countries
• 169 specific resuscitation questions in
standard PICO ( population, intervention,
comparison, Outcome ) format
• Specific GRADE ( Grading of
Recommendations Assessment, Development
and Evaluation ) methodology

7. 2015 CPR Guidelines Developmental
Process
• The output of the GRADE process :
 2015 International Consensus on CPR and ECC
Science With Treatment Recommendations
(CoSTR)
• Recent International Consensus Conference in
Dallas ( Feb 2015 )
 Experts discussed & debated

8. • Emphasize the interactions between the
emergency medical dispatcher, the bystander
who provides CPR and the use of AED and
EMS
• Public CPR – hands- only CPR
Highlights in BLS 2015

9. • Emphasize the importance of early diagnosis
of cardiac arrest and the provision of
dispatcher assisted CPR( Telephone CPR)
through MECC Call Dispatcher via MERS 999
call
Highlights in BLS 2015

10. Highlights in BLS 2015
• Emphasis on high quality CPR
 The compression rate is 100 – 120 compression /
minute
 Compression depth : at least 5 cm but not more
than 6 cm
 Minimal Interruption (less than 10 sec)
 Full chest wall recoil

11. • Be aware that seizures could be a sign of
Cardiac Arrest
• Suggest to use of Real Time Audiovisual
feedback and prompt devices during CPR in
clinical practice and against in isolation
practice
Highlights in BLS 2015

12. 2015 ALS guidelines
What’s
new

13. 2015 ALS Guidelines
• ILCOR review focused on 42 topics
• Organized in the approximate sequence of
ACLS interventions:
 defibrillation
 airway, oxygenation and ventilation
 circulatory support
 monitoring during CPR
 drugs during CPR

14. Chain of prevention:
 staff education
 Monitoring of patients
 Recognition of the patient’s deterioration
 Effective emergency response system
Post
cardiac
arrest
care

15. Defibrillation
• Minimal changes
• Defibrillators using biphasic waveform are preferred
( greater success in arrhythmia termination )
• No difference in energy joule used
• Pre-shock pause should be less than 5 seconds
• Self adhesive pad should be used if available

16. Defibrillation
• Resume CPR immediately after a shock ( not
assessing rhythm/ checking for pulse post
defibrillation attempt )
• Even if the defibrillation is successful to
restore a perfusing rhythm, it takes time to
establish a post shock circulation

17. Defibrillation : energy level for
subsequent shock ( VF/pVT )
• Higher termination of arrhythmia in the
escalating higher energy group
But, no significant differences in ROSC, survival to
discharge, or survival with favourable neurologic
outcome
• Both strategies are acceptable
• It is reasonable that selection of fixed versus
escalating energy for subsequent shocks be based
on the specific manufacturer’s instructions

18. ‘Refibrillation’ ( recurrent VF )
• Defined as :
 ‘recurrence of VF during a documented cardiac
arrest episode, occurring after initial termination
of VF while the patient remains under the care of
the same providers
 higher subsequent energy level is more
beneficial for the termination of the refibrillation

19. Defibrillation : single shock vs stacked
shock ( VF/pVT )
• One RCT, 845 OHCA , no difference in 1- year survival
with these two protocols
• A single shock strategy is reasonable for defibrillation
( benefit of CPR in providing myocardial blood flow
post shock period / outcome is improved by
minimizing interruption to chest compression )

20. Witnessed, monitored VF/pVT…
• When there is a witnessed VF/pVT in a
monitored patient and he/she is already
connected to a manual defibrillator, give up to
3 quick , successive (stacked ) shocks
• Reason :
 it is unlikely that chest compressions will improve
the already very high chance of ROSC when
defibrillation occurs early in the electrical phase,
immediately after onset of VF.

21. Witnessed, monitored VF/pVT…
• If this initial three-shock strategy is
unsuccessful for a monitored VF/pVT cardiac
arrest, the ALS algorithm should be followed
and these three-shocks treated as if only the
first single shock has been given.

22. Airway, oxygenation and ventilation

23. Oxygen during CPR
• CPR goal: restore the energy state of the heart so it
can resume mechanical work and to maintain the
energy state & minimize ischemic injury
• Adequate oxygen delivery is necessary
• Detrimental effects of hyperoxia that may exist in the
immediate post–cardiac arrest period should not be
extrapolated to the low-flow state of CPR
maximal feasible inspired oxygen during CPR
is recommended

24. Bag-mask ventilation vs advanced
airway placement during CPR

25. Bag-mask ventilation vs advanced
airway placement during CPR
• No high quality data to favor either airway
strategy
• Evaluating the retrospective studies is
challenging
• More severe physiologic compromise will
require more invasive care

26. Bag-mask ventilation vs advanced
airway placement during CPR
• Either a bag-mask device or an advanced
airway may be used for oxygenation and
ventilation during CPR in both the in hospital
and out-of-hospital setting
• The choice of bag-mask device versus
advanced airway insertion will be determined
by the skill and experience of the provider

27. Drugs
• although drugs are still included among ALS
interventions, they are of secondary
importance to high-quality uninterrupted
chest compressions and early defibrillation.

28. Adrenaline vs no adrenaline
• Significant higher rates of pre-hospital ROSC &
survival to hospital admission compared to
placebo
• Long term outcome such as survival to
hospital discharge or good neurological
survival – no better or worse

29. • Large observational study ( 25095 patients ) of
cardiac arrest with non-shockable rhythm
compared epinephrine given at
 1 to 3 minutes
 4 to 6 minutes
 7 to 9 minutes
 greater than 9 minutes
• Results : there is association between early
administration of epinephrine and increased
ROSC, survival to hospital discharge, and
neurologically intact survival.

30. Timing of administration of adrenaline
( non-shockable rhythm )
• It may be reasonable to administer
epinephrine as soon as feasible after the
onset of cardiac arrest due to an initial
non-shockable rhythm.

31. Adrenaline vs vasopressin
• Comparing outcomes (ROSC, survival to
discharge, or neurological outcome) with
vasopressin versus adrenaline as a first line
vasopressor in cardiac arrest ( series of RCTs )
NO difference
• Vasopressin in combination with epinephrine
offers no advantage as a substitute for
standard-dose epinephrine in cardiac arrest

32. • Therefore, to simplify the algorithm, Adult
Cardiac Arrest Algorithm– 2015 Update.
Vasopressin removed

33. Steroid
• Use of steroid is of
uncertain benefit
• no data to recommend
for or against the
routine use of steroids
alone
• Combination of
vasopressin, steroid and
epinephrine may be
considered
OHCA IHCA

34. Vasopressin, steroid, epinephrine
protocol
• Conclusions:
Improved survival to hospital discharge with
favorable neurological status among patients
with cardiac arrest requiring vasopressors,
combined vasopressin-epinephrine and
methylprednisolone during CPR and stress-dose of
hydrocortisone in post resuscitation shock,
compared with epinephrine/saline placebo

35. Extracorporeal cardiopulmonary
resuscitation (eCPR )
• The 2015 ILCOR systematic review compared
the use of ECPR (or ECMO) techniques for
adult patients with IHCA and OHCA to
conventional (manual or mechanical) CPR, in
regard to ROSC, survival, and good neurologic
outcome.

36. Extracorporeal cardiopulmonary
resuscitation (eCPR )
• require vascular access and a circuit with a
pump and oxygenator and can provide a
circulation of oxygenated blood to restore
tissue perfusion
• has the potential to buy time for restoration of
an adequate spontaneous circulation, and
treatment of reversible underlying conditions

37. Veno-arterial extracorporeal membrane oxygenation
for cardiogenic shock & cardiac arrest: A meta-analysis
• 22 observational studies, 1199 patients
• Survival to hospital discharge : 40.2 % ( average )
• 30 –days survival, weighted estimate : 52.8%
• Significant morbidity ( complications )
• Technical expertise
• High cost of ECMO treatment
• Necessitates appropriate case selection in order to
maximize its potential benefits

38. Extracorporeal cardiopulmonary
resuscitation (eCPR )
• Improved outcome when
o there is reversible cause for cardiac arrest ( e.g.
MI, PE, severe hypothermia, poisoning )
o When there is little comorbidity
o When cardiac arrest is witnessed
o When individual receives immediate high quality
CPR
o eCPR is implemented early (within 1 h of collapse)

39. Post Cardiac Arrest Care

40. Keeping the heart beat (ROSC )…..
• ROSC is just a starting point & the first step
towards the goal of complete recovery of
cardiac arrest
Is the job
done?

41. Post cardiac arrest syndrome
• Complex pathophysiological process
• When does it start?
• How does it happen?

42. Post cardiac arrest syndrome
• No flow
• anoxic
Cardiac
arrest
• Minimal flow
• ischemic
CPR
• reperfusion
ROSC

43. • Post anoxic-ischemic-reperfusion syndrome
• Triggered by cardiac arrest and return of
spontaneous circulation
• Main component:
 early but severe circulatory dysfunction
 may lead to multi-organ failure and death
Post Cardiac arrest Syndrome

44. Myocardial dysfunction
accounts for the most
death for the first 3
days
Starts to recover after
2-3 days post cardiac
arrest
Anoxic brain injury
may be exacerbated by
microcirculatory failure,
hypo/hypercarbia, pyrexia,
hypo/hyperoxaemia,
hypo/hyperglycaemia,
hypotension
Multi-organ failure
Systemic ischemic
/reperfusion activated
immune & coagulation
problem
Non specific systemic
inflammatory response
syndrome
infection
Post Cardiac arrest Syndrome

45. • Clinical features:
 its intensity varies
 but , roughly proportional to the duration of ‘ no
flow’ and ‘ low flow ‘
• Overall outcome depends on:
 underlying cause of collapse
 availability of early high quality CPR
 Post resuscitation care
Post cardiac arrest syndrome

46. Post Cardiac Arrest Care

47. Control of ventilation
• Consider tracheal intubation, sedation and
controlled ventilation in any patient with
obtunded cerebral function
• Adequate sedation reduce O2
consumption
• Boluses dose of neuromuscular blocking agent
may be required ( esp using targeted
temperature management /TTM )
prevent shivering

48. Control of ventilation
• keep normocarbia ( PaCO2 35-45mmHg )
• No hyperoxia
• AVOID hypoxia ( also harmful )
titrate the inspired oxygen concentration to
maintain the arterial blood oxygen saturation
in the range of 94–98%

49. • Coronary reperfusion
• Hemodynamic management
Circulation control

50. Coronary reperfusion
• Coronary angiography should be performed
emergently for OHCA patients with suspected cardiac
etiology of arrest and ST elevation on ECG
• Emergency coronary angiography is reasonable for
selected (eg, electrically or hemodynamically
unstable) adult patients who are comatose after
OHCA of suspected cardiac origin but without ST
elevation on ECG

51. • optimal targets for mean arterial pressure
and/or systolic arterial pressure remain
unknown
• Study – MAP ≥ 70 mmHg , good neurological
outcome
• Tachycardia – bad outcome
• Relative adrenal insufficiency- VSE protocol
with good outcome
Hemodynamic management

52. Optimizing Neurological Recovery
• Adequate cerebral perfusion
• Targeted Temperature Management
• Control of seizures
• Glucose control

53. How does hypothermia help in
optimizing the neurological recovery

54. Hypothermia
• Suppresses many pathways delayed cell
death
• Decreases CMRO2 ( 6% per each 1 ◦C reduction in
core temperature)
• Reduces the release of excitatory amino acids and
free radicals
• Blocks intracellular consequences of excitotoxin
exposure
• Reduces inflammatory response associated with
post cardiac arrest syndrome

55. Targeted temperature Management
( TTM )
• Adopted term in 2015 as compared to
‘therapeutic hypothermia’ in 2010
• Refers to ‘ active control of temperature at any
target ‘
• Specific features of the collapsed victim may
favor certain selected target temperature over
another for TTM

56. • Recommendations:
the comatose adult patients with ROSC after
cardiac arrest , must have TTM
select and maintain a constant temperature
between 32-36◦C during TTM for at least 24 hours
Pre-hospital cooling with large volume of cooled
IVD immediately after ROSC is not recommended
Targeted temperature Management
( TTM )

57. Seizures Control
• Seizure is common after cardiac arrest ( 30% )
• Myoclonus – most common
• Others : focal or generalized tonic-clonic
seizures or mixed type
• MUST treat ( seizures may increase CMRO2
and exacerbate brain injury caused by cardiac
arrest )
• BUT, routine seizure prophylaxis is not
recommended

58. Glucose Control
• blood glucose after cardiac arrest poor
neurological outcome
• In critically ill patient , tight sugar control ( 4-
6mmol-1 ) – increased 90 days mortality
compared to those with conventional sugar
control ( 10 mmol-1or less ) & associated with
frequent hypoglycemic episodes

59. Glucose Control
• Increased blood glucose variability
– associated with increased mortality and
unfavourable neurological outcome after cardiac
arrest
• Recommendation :
 maintain the blood glucose at ≤10 mmol-1 and
avoid hypoglycaemia following ROSC

60. Post Cardiac Arrest….
• Death is common
 hypoxic-ischemic brain injury
 active withdrawal of life sustaining treatment
(WLST) based on prognostication of a poor
neurological outcome
• Optimal timing for prognostication in post
cardiac arrest patient is important

61. When to prognosticate?
• The earliest time for prognostication using in
patients treated with TTM, may be 72 hours
after return to normothermia
• The earliest time to prognosticate a poor
neurologic outcome in patients not treated
with TTM is 72 hours after cardiac arrest
 sedation/muscle relaxant---- need to wait ….