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Tuesday
Feb162016

Advanced Cardiovascular Life Support and ACS

Bob Elling, MPA, EMT-P

(Part 3 of a 6-part series: CPR, ECC, and First Aid Guidelines: Version 2015)

Advanced Cardiovascular Life Support and ACS

A number of topics were addressed in the 2015 Guidelines on adult advanced cardiovascular life support (ACLS) and acute coronary syndromes (ACS) that will be incorporated into updated protocols and procedures. Let’s take a closer look at the specifics here.

Advanced Cardiovascular Life Support

Adjuncts to CPR

  • When supplementary oxygen is available, it may be reasonable to use the maximal feasible inspired oxygen concentration during CPR (Class IIb).
  • Although no clinical study has examined whether titrating resuscitative efforts to physiologic parameters during CPR improves outcome, it may be reasonable to use physiologic parameters (quantitative waveform capnography, arterial relaxation diastolic pressure, arterial pressure monitoring, and central venous oxygen saturation) when feasible to monitor and optimize CPR quality, guide vasopressor therapy, and detect ROSC (Class IIb).

Adjuncts for Airway Control and Ventilation

  • Either a bag-mask device or an advanced airway may be used for oxygenation and ventilation during CPR in both in-hospital and out-of-hospital settings (Class IIb).
  • For health care providers trained in their use, either a supraglottic airway (SGA) device or an endotracheal tube (ETT) may be used as the initial advanced airway during CPR (Class IIb).
  • Continuous waveform capnography is recommended in addition to clinical assessment as the most reliable method of confirming and monitoring correct placement of an ETT (Class I).
  • If continuous waveform capnography is not available, a nonwaveform CO2 detector, esophageal detector device, or ultrasound used by an experienced operator is a reasonable alternative (Class IIa).
  • After placement of an advanced airway, it may be reasonable for the provider to deliver 1 breath every 6 seconds (10 breaths/min) while continuous chest compressions are being performed (Class IIb).

Management of Cardiac Arrest

  • Defibrillators (using BTE, RLB, or monophasic waveforms) are recommended to treat atrial and ventricular arrhythmias (Class I).
  • Based on their greater success in arrhythmia termination, defibrillators using biphasic waveforms (BTE or RLB) are preferred to monophasic defibrillators for treatment of both atrial and ventricular arrhythmias (Class IIa).
  • In the absence of conclusive evidence that one biphasic waveform is superior to another in termination of VF, it is reasonable to use the device manufacturer’s recommended energy dose for the first shock. If this dose is not known, defibrillation at the maximal dose may be considered (Class IIb).
  • It is reasonable that selection of fixed versus escalating energy for subsequent shocks be based on the specific device manufacturer’s instructions (Class IIa).
  • If using a manual defibrillator capable of escalating energies, higher energy for the second and subsequent shocks may be considered (Class IIb).
  • A single-shock strategy (as opposed to stacked shocks) is reasonable for defibrillation (Class IIa).
  • Amiodarone may be considered for VF/pVT that is unresponsive to CPR, defibrillation, and vasopressor therapy (Class IIb).
  • Lidocaine may be considered as an alternative to amiodarone for VF/pVT that is unresponsive to CPR, defibrillation, and vasopressor therapy (Class IIb,).
  • The routine use of magnesium for VF/pVT is not recommended in adult patients (Class III).
  • There is inadequate evidence to support the routine use of lidocaine after cardiac arrest. However, initiation or continuation of lidocaine may be considered immediately after ROSC from cardiac arrest due to VF/pVT (Class IIb).
  • There is inadequate evidence to support the routine use of a beta-blocker after cardiac arrest. However, the initiation or continuation of an oral or intravenous beta-blocker may be considered early after hospitalization from cardiac arrest due to VF/pVT (Class IIb).
  • Standard-dose epinephrine (1 mg every 3 to 5 minutes) may be reasonable for patients in cardiac arrest (Class IIb).
  • High-dose epinephrine is not recommended for routine use in cardiac arrest (Class III).
  • Vasopressin offers no advantage as a substitute for epinephrine in cardiac arrest (Class IIb).
  • Vasopressin in combination with epinephrine offers no advantage as a substitute for standard-dose epinephrine in cardiac arrest (Class IIb).
  • It may be reasonable to administer epinephrine as soon as feasible after the onset of cardiac arrest due to an initial nonshockable rhythm (Class IIb).
  • For patients with OHCA, use of steroids during CPR is of uncertain benefit (Class IIb).
  • In intubated patients, failure to achieve an etco2 of greater than 10 mm Hg 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 should not be used in isolation (Class IIb).
  • In non-intubated patients, a specific etco2 cutoff value at any time during CPR should not be used as an indicator to end resuscitative efforts (Class III).

Post-Cardiac Arrest Care

Cardiovascular Care and Hemodynamic Goals 

  • 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 (Class I).
  • Emergent 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 (Class IIa).
  • Coronary angiography is reasonable in post–cardiac arrest patients for whom coronary angiography is indicated regardless of whether the patient is comatose or awake (Class IIa).
  • Avoiding and immediately correcting hypotension (systolic BP less than 90 mm Hg, MAP less than 65 mm Hg) during post-resuscitation care may be reasonable (Class IIb).

Targeted Temperature Management (TTM) and Other Critical Care Interventions

  • We 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) for non-VF/pVT (ie, “non-shockable”) and in-hospital cardiac arrest.
  • We recommend selecting and maintaining a constant temperature between 32°C and 36°C during TTM (Class I).
  • It is reasonable that TTM be maintained for at least 24 hours after achieving the target temperature (Class IIa).
  • We recommend against the routine prehospital cooling of patients after ROSC with rapid infusion of cold intravenous fluids (Class III).
  • 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 (Class I).
  • Patients who do not have ROSC after resuscitation efforts and who would otherwise have termination of efforts may be considered candidates for kidney or liver donation in settings where such program exist (Class IIb).

Acute Coronary Syndromes

Diagnostic Interventions

  • Prehospital 12-lead ECG should be acquired early for patients with possible ACS (Class I).
  • Prehospital notification of the receiving hospital (if fibrinolysis is the likely reperfusion strategy) and/or prehospital activation of the catheterization laboratory should occur for all patients with a recognized STEMI on prehospital ECG (Class I).
  • Because of high false-negative rates, we recommend that computer-assisted ECG interpretation not be used as the sole means to diagnose STEMI (Class III).
  • We recommend that computer-assisted ECG interpretation be used in conjunction with physician or trained-provider interpretation to recognize STEMI (Class IIb).
  • While transmission of the prehospital ECG to the ED physician may improve PPV and therapeutic decision making regarding adult patients with suspected STEMI, if transmission is not performed, it may be reasonable for trained-nonphysician ECG interpretation to be used as the basis for decision making, including activation of the catheterization laboratory, administration of fibrinolysis, and selection of the destination hospital (Class IIa).

Therapeutic Interventions

  • The usefulness of supplementary oxygen therapy has not been established in normoxic patients. In the prehospital, ED, and hospital settings, the withholding of supplementary oxygen therapy in normoxic patients with suspected or confirmed ACS may be considered (Class IIb).
  • Where prehospital fibrinolysis is available as part of a STEMI system of care, and in-hospital fibrinolysis is the alternative treatment strategy, it is reasonable to administer prehospital fibrinolysis when transport times are more than 30 minutes (Class IIa).
  • If fibrinolytic therapy is provided, immediate transfer to a PCI center for cardiac angiography within 3 to 24 hours may be considered (Class IIb).
  • Regardless of whether the time of symptom onset is known, the interval between first medical contact and reperfusion should not exceed 120 minutes (Class I).
  • When STEMI patients cannot be transferred to a PCI-capable hospital in a timely manner, fibrinolytic therapy with routine transfer for angiography may be an acceptable alternative to immediate transfer to PPCI (Class IIb).
  • When fibrinolytic therapy is administered to STEMI patients in a non-PCI-capable hospital, it may be reasonable to transport all post-fibrinolysis patients for early routine angiography in the first 3 to 6 hours and up to 24 hours later, rather than to transport post-fibrinolysis patients only when they require ischemia-guided angiography (Class IIb).

The next section of this blog will go into the specifics on special circumstances in resuscitation. If you want to read all the details and background, take a look at the Supplement to Circulation, volume 132, number 18, supplement 2, November 3, 2015.

See you in the streets!

 

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