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CPR2015 update: Adult ACLS

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CPR2015 update: Adult Advanced Cardiovascular Life Support

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CPR2015 update: Adult ACLS

  1. 1. Adult Advanced Cardiovascular Life Support Part 7
  2. 2. Oxygen Dose During CPR 2015 Recommendation-updated Class When supplementary oxygen is available, it may be reasonable to use the maximal feasible inspired oxygen concentration during CPR IIb, LOE C-EO The higher ranges of arterial Po2 during CPR were associated with an increase in hospital admission rates. However, there was no statistical difference in overall neurologic survival
  3. 3. Monitoring Physiologic Parameters During CPR 2015 Recommendation—Updated Class It may be reasonable to use physiologic parameters (quantitative waveform capnography, arterial relaxation diastolic pressure, arterial pressure monitoring, and ScVO2) when feasible to monitor and optimize CPR quality, guide vasopressor therapy, and detect ROSC IIb, LOE C-EO
  4. 4. Ultrasound During Cardiac Arrest 2015 Recommendations—Updated Class Ultrasound (cardiac or noncardiac) may be considered during the management of cardiac arrest, although its usefulness has not been well established Class IIb, LOE C-EO
  5. 5. Ultrasound During Cardiac Arrest 2015 Recommendations—Updated Class If a qualified sonographer is present and use of ultrasound does not interfere with the standard cardiac arrest treatment protocol, then ultrasound may be considered as an adjunct to standard patient evaluation IIb, LOE C-EO
  6. 6. Bag-Mask Ventilation Compared With Any Advanced Airway During CPR 2015 Recommendations—Updated Class Either a bag-mask device or an advanced airway may be used for oxygenation and ventilation during CPR in both the inhospital and out-of- hospital setting IIb, LOE C-LD For healthcare providers trained in their use, either an SGA device or an ETT may be used as the initial Advanced airway during CPR IIb, LOE C-LD
  7. 7. Clinical Assessment of Tracheal Tube Placement 2015 Recommendations—Updated Class Continuous waveform capnography is recommended in addition to clinical assessment as the most reliable method of confirming and monitoring correct placement of an ETT I,LOE C-LD If continuous waveform capnometry is not available, a nonwaveform CO2 detector, esophageal detector device, or ultrasound used by an experienced operator is a reasonable alternative IIa, LOE C-LD
  8. 8. Ventilation After Advanced Airway Placement 2015 Recommendation—Updated Class After placement of an advanced airway, it may be reasonable for the provider to deliver 1 breath every 6 seconds (10breaths/min) while continuous chest compressions are being performed IIb, LOE C-LD
  9. 9. Defibrillation Strategies for VF or Pulseless VT: WaveformEnergy and First-Shock Success 2015 Recommendations—Updated Class Defibrillators (using BTE, RLB, or monophasic waveforms) are recommended to treat atrial and ventricular arrhythmias I, LOE B-NR Using biphasic waveforms (BTE or RLB) are preferred to monophasic defibrillators for treatment of both atrial and ventricular arrhythmias IIa, LOE B-R
  10. 10. Defibrillation Strategies for VF or Pulseless VT: Waveform Energy and First-Shock Success 2015 Recommendations—Updated Class it is reasonable to use the manufacturer’s recommended energy dose for the first shock. If this is not known, defibrillation at the maximal dose may be considered IIb, LOE C-LD
  11. 11. Defibrillation Strategies for VF or Pulseless VT: Energy Dose for Subsequent Shocks 2015 Recommendations—Updated Class It is reasonable that selection of fixed versus escalating energy for subsequent shocks be based on the specific manufacturer’s instructions IIa, LOE C-LD If using a manual defibrillator capable of escalating energies,higher energy for second and subsequent shocks may be considered IIb, LOE C-LD
  12. 12. Defibrillation Strategies for VF or Pulseless VT : Single Shocks Versus Stacked Shocks 2015 Recommendation—Updated Class A single-shock strategy (as opposed to stacked shocks) is reasonable for defibrillation IIa, LOE B-NR
  13. 13. Antiarrhythmic Therapy for Refractory VF/pVT Arrest 2015 Recommendations—Updated Class Amiodarone may be considered for VF/pVT that is unresponsive to CPR, defibrillation, and a vasopressor therapy IIb, LOE B-R Lidocaine may be considered as an alternative to amiodarone for VF/pVT that is unresponsive to CPR, defibrillation,and vasopressor therapy IIb, LOE C-LD The routine use of magnesium for VF/pVT is not recommended in adult patients III: No Benefit, LOE B-R
  14. 14. Antiarrhythmic Drugs After Resuscitation 2015 Recommendations—New Class •There is inadequate evidence to support the routine use of lidocaine after cardiac arrest. •However, the initiation or continuation of lidocaine may be considered immediately after ROSC from cardiac arrest due to VF/pVT IIb, LOE C-LD
  15. 15. Antiarrhythmic Drugs After Resuscitation 2015 Recommendations—New Class •There is inadequate evidence to support the routine use of a β-blocker after cardiac arrest. •However, the initiation or continuation of an oral or intravenous β-blocker may be considered early after hospitalization from cardiac arrest due to VF/pVT IIb, LOE C-LD
  16. 16. Standard-Dose Epinephrine 2015 Recommendation—Updated Class Standard-dose epinephrine (1 mg every 3 to 5 minutes) may be reasonable for patients in cardiac arrest IIb, LOE B-R
  17. 17. Standard Dose Epinephrine Versus High-Dose Epinephrine 2015 Recommendation—New Class High-dose epinephrine is not recommended for routine use in cardiac arrest III: No Benefit, LOE B-R
  18. 18. Epinephrine Versus Vasopressin 2015 Recommendation—Updated Class Vasopressin offers no advantage as a substitute for epinephrine in cardiac arrest IIb, LOE B-R •The removal of vasopressin has been noted in the Adult Cardiac Arrest Algorithm
  19. 19. Epinephrine Versus Vasopressin in Combination With Epinephrine 2015 Recommendation—New Class Vasopressin in combination with epinephrine offers no advantage as a substitute for standard-dose epinephrine in cardiac arrest IIb, LOE B-R
  20. 20. Timing of Administration of Epinephrine 2015 Recommendations—Updated Class It may be reasonable to administer epinephrine as soon as feasible after the onset of cardiac arrest due to an initial nonshockable rhythm IIb, LOE C-LD
  21. 21. Steroids 2015 Recommendations—New Class •In IHCA, the combination of intra-arrest vasopressin, epinephrine, and methylprednisolone and post-arrest hydrocortisone may be considered; •However, further studies are needed before recommending the routine use of this therapeutic strategy IIb, LOE C-LD
  22. 22. Steroids 2015 Recommendations—New Class For patients with OHCA, use of steroids during CPR is of uncertain benefit IIb, LOE C- LD
  23. 23. Prognostication During CPR: End-Tidal CO2 2015 Recommendations—New Class In intubated patients, failure to achieve an ETCO2 > 10 mmHg by waveform capnography after 20 minutes of CPR may be considered as one component of a multimodal approach to decide when to end resuscitative efforts, but it should not be used in isolation IIb,LOE C- LD
  24. 24. Prognostication During CPR: End-Tidal CO2 2015 Recommendations—New Class In nonintubated patients, a specific ETCO2 cutoff value at any time during CPR should not be used as an indication to end resuscitative efforts III: Harm, LOE C-EO
  25. 25. Overview of Extracorporeal CPR 2015 Recommendation—New Class There is insufficient evidence to recommend the routine use of ECPR for patients with cardiac arrest. In settings where it can be rapidly implemented, ECPR may be considered for select cardiac arrest patients for whom the suspected etiology of the cardiac arrest is potentially reversible during a limited period of mechanical cardiorespiratory support IIb, LOE C-LD
  26. 26. Post–Cardiac Arrest Care Part 8
  27. 27. Acute Cardiovascular Interventions 2015 Recommendations—Updated Class Coronary angiography should be performed emergently (rather than later in the hospital stay or not at all) for OHCA patients with suspected cardiac etiology of arrest and ST elevation on ECG I, LOE B-NR
  28. 28. Acute Cardiovascular Interventions 2015 Recommendations—Updated Class Emergency coronary angiography is reasonable for select (eg, electrically or hemodynamically unstable) adult patients who are comatose after OHCA of suspected cardiac origin but without ST elevation on ECG IIa, LOE B- NR
  29. 29. Acute Cardiovascular Interventions 2015 Recommendations—Updated Class Coronary angiography is reasonable in post–cardiac arrest patients for whom coronary angiography is indicated regardless of whether the patient is comatose or awake IIa, LOE C-LD
  30. 30. Hemodynamic Goals 2015 Recommendation—New Class Avoiding and immediately correcting hypotension (systolic blood pressure less than 90 mm Hg, MAP less than 65 mm Hg) during postresuscitation care may be reasonable IIb, LOE C-LD
  31. 31. Induced Hypothermia 2015 Recommendations—Updated Class Recommend that comatose (ie, lack of meaningful response to verbal commands) adult patients with ROSC after cardiac arrest have TTM •Class I, LOE B-R for VF/pVT OHCA •Class I, LOE C-EO for non-VF/pVT Recommend selecting and maintaining a constant temperature between 32C and 36C during TTM Class I, LOE B-R It is reasonable that TTM be maintained for at least 24 hours after achieving target temperature Class IIa, LOE C- EO
  32. 32. Hypothermia in the Prehospital Setting 2015 Recommendation—New Class We recommend against the routine prehospital cooling of patients after ROSC with rapid infusion of cold intravenous fluids Classs III: No benefit, LOE A
  33. 33. Avoidance of Hyperthermia 2015 Recommendation—New Class It may be reasonable to actively prevent fever in comatose patients after TTM IIb, LOE C-LD
  34. 34. Seizure Management 2015 Recommendations—Updated Class An EEG for the diagnosis of seizure should be promptly performed and interpreted, and then should be monitored frequently or continuously in comatose patients after ROSC I, LOE C-LD The same anticonvulsant regimens for the treatment of status epilepticus caused by other etiologies may be considered after cardiac arrest IIb, LOE C-LD
  35. 35. Ventilation 2015 Recommendation—Updated Class Maintaining the PaCo2 within a normal physiological range, taking into account any temperature correction, may be reasonable IIb, LOE B-NR
  36. 36. Oxygenation 2015 Recommendations—New and Updated Class To avoid hypoxia in adults with ROSC after cardiac arrest, it is reasonable to use the highest available oxygen concentration until the arterial oxyhemoglobin saturation or the partial pressure of arterial oxygen can be measured IIa, LOE C-EO
  37. 37. Oxygenation 2015 Recommendations—New and Updated Class When resources are available to titrate the Fio2 and to monitor O2sat, it is reasonable to decrease the Fio2 when oxyhemoglobin saturation is 100%, provided O2sat can be maintained at 94% or greater IIa, LOE C-LD
  38. 38. Glucose Control 2015 Recommendation—Updated Class The benefit of any specific target range of glucose managementis uncertain in adults with ROSC after cardiac arrest IIb, LOE B-R
  39. 39. Timing of Outcome Prediction 2015 Recommendations—New and Updated Class The earliest time for prognostication using clinical examination in patients treated with TTM, where sedation or paralysis could be a confounder, may be 72 hours after return to normothermia IIb, LOE C-EO
  40. 40. Timing of Outcome Prediction 2015 Recommendations—New and Updated Class Recommend the earliest time to prognosticate a poor neurologic outcome using clinical examination in patients not treated with TTM is 72 hours after cardiac arrest I, LOE B- NR This time until prognostication can be even longer than 72 hours after cardiac arrest if the residual effect of sedation or paralysis confounds the clinical examination IIa, LOE C- LD
  41. 41. Clinical Examination Findings That Predict Outcome 2015 Recommendations—New and Updated Class In comatose patients who are not treated with TTM, the absence of pupillary reflex to light at 72 hours or more after cardiac arrest is a reasonable exam finding with which to predict poor neurologic outcome IIa, LOE B- NR
  42. 42. Clinical Examination Findings That Predict Outcome 2015 Recommendations—New and Updated Class In comatose patients who are treated with TTM, the absence of pupillary reflex to light at 72 hours or more after cardiac arrest is useful to predict poor neurologic outcome I, LOE B- NR
  43. 43. Clinical Examination Findings That Predict Outcome 2015 Recommendations—New and Updated Class Recommend that, given their unacceptable FPRs, the findings of either absent motor movements or extensor posturing should not be used alone for predicting a poor neurologic outcome III: Harm, LOE B-NR The motor examination may be a reasonable means to identify the population who need further prognostic testing to predict poor outcome IIb, LOE B- NR
  44. 44. Clinical Examination Findings That Predict Outcome 2015 Recommendations—New and Updated Class Recommend that the presence of myoclonus, which is distinct from status myoclonus, should not be used to predict poor neurologic outcomes because of the high FPR Class III, Harm, LOE B- NR
  45. 45. Clinical Examination Findings That Predict Outcome 2015 Recommendations—New and Updated Class In combination with other diagnostic tests at 72 or more hours after cardiac arrest, the presence of status myoclonus during the first 72 to 120 hours after cardiac arrest is a reasonable finding to help predict poor neurologic outcomes IIa, LOE B-NR
  46. 46. EEG Findings to Predict Outcome 2015 Recommendations—Updated Class In comatose post–cardiac arrest patients who are treated with TTM, it may be reasonable to consider persistent absence of EEG reactivity to external stimuli at 72 hours after cardiac arrest, and persistent burst suppression on EEG after rewarming, to predict a poor outcome IIb, LOE B- NR
  47. 47. EEG Findings to Predict Outcome 2015 Recommendations—Updated Class Intractable and persistent (>72 hours) status epilepticus in the absence of EEG reactivity to external stimuli may be reasonable to predict poor outcome IIb, LOE B-NR
  48. 48. EEG Findings to Predict Outcome 2015 Recommendations—Updated Class In comatose post–cardiac arrest patients who are not treated with TTM, it may be reasonable to consider the presence of burst suppression on EEG at 72 hours or more after cardiac arrest, in combination with other predictors, to predict a poor neurologic outcome IIb, LOE B- NR
  49. 49. Evoked Potentials to Predict Outcome 2015 Recommendations—Updated Class In patients who are comatose after resuscitation from cardiac arrest regardless of treatment with TTM, it is reasonable to consider bilateral absence of the N20 SSEP wave 24 to 72 hours after cardiac arrest or after rewarming a predictor of poor outcome IIa, LOE B-NR
  50. 50. Imaging Tests to Predict Outcome 2015 Recommendations—New Class In patients who are comatose after resuscitation from cardiac arrest and not treated with TTM, it may be reasonable to use the presence of a marked reduction of the GWR on brain CT obtained within 2 hours after cardiac arrest to predict poor outcome IIb, LOE B- NR
  51. 51. Imaging Tests to Predict Outcome 2015 Recommendations—New Class It may be reasonable to consider extensive restriction of diffusion on brain MRI at 2 to 6 days after cardiac arrest in combination with other established predictors to predict a poor neurologic outcome IIb, LOE B- NR
  52. 52. Blood Markers to Predict Outcome 2015 Recommendations—Updated Class Given the possibility of high FPRs, blood levels of NSE and S-100B should not be used alone to predict a poor neurologic outcome III: Harm, LOE C-LD
  53. 53. Blood Markers to Predict Outcome 2015 Recommendations—Updated Class When performed with other prognostic tests at 72 hours or more after cardiac arrest, it may be reasonable to consider high serum values of NSE at 48 to 72 hours after cardiac arrest to support the prognosis of a poor neurologic outcome IIb, LOE B- NR Especially if repeated sampling reveals persistently high values IIb, LOE C- LD
  54. 54. Organ Donation 2015 Recommendations—Updated and New Class We recommend that all patients who are resuscitated from cardiac arrest but who subsequently progress to death or brain death be evaluated for organ donation I, LOE B-NR

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