AHA Guidelines 2015 An overview of whats new Ed Racht Lynn White First amp foremost Welcome to our new colleagues from Rural Metro Who are we now Largest single US provider of 911 services ID: 911736
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Slide1
Slide2Resuscitation Update 2015
Slide3AHA Guidelines
2015
An overview of what’s new…
Ed Racht
Lynn White
Slide4First & foremost…
Welcome to our new colleagues from Rural Metro…
Slide5Who are we now?
Largest single US provider of 911 services
Practices in 40 States & DC
26,188 caregivers
4.4 Million patient transports per yearWe cover a population of 43 Million people (Size of Spain)14% of the US Population depends on us125 Medical Directors
~ 32,000 cardiac arrests per year15% of all arrests that occur in the US
Slide6Slide7Slide8Slide9Practices are determined by local Medical Oversight…
Remember that all changes in medical practice are determined by your Medical Director and specific practice protocols and guidelines.
Slide10AHA
The process
Started in 2012
7 Task Forces
BLS
ALSACSPediatric BLS & ALS
Neonatal ResuscitationEIT (Education / Implementation / Teams)First Aid
AHA Guidelines 2015
Slide11The evidence evaluation process…
International Liaison Committee on Resuscitation (ILCOR)
Formed in 1992
Consists of most of the world’s resuscitation councils
Collects, discusses and debates scientific evidence
ILCOR 2015
39 Countries
232 participants
Slide12AHA
The process
Methodologic approach for evidence evaluation & recommendations
GRADE Guideline Tool
Developed questions
Detailed literature review
AHA Guidelines 2015
Slide13Change…
Slide14“
New and revised treatment recommendations do not imply that clinical care that involves the use of previously published guidelines is either unsafe or ineffective
”
A key philosophy…
2015 Guidelines are considered an update to 2010 Guidelines
Slide15AHA
From here forward…
AHA Guidelines 2015
Slide16e
ccguidelines.heart.org
Slide17Slide18315 classified recommendations
78 Class I recommendations (25%) –
“Is recommended”
217 Class II recommendations (68%) –
“Reasonable or may be reasonable”
20 Class III recommendations (7%) – “Is not recommended / may be harmful”
Level of Evidence3
(1%) are based on Level of Evidence (LOE)
A
50
(15%) are based on LOE B-R (randomized studies
)
46 (15%) are based on LOE B-NR (nonrandomized studies
)
145
(46%) are based on LOE C-LD (limited data
)
73
(23%) are based on LOE
C-EO (expert opinion consensus)
The
nitty
gritty details
Slide19Ischemic Heart Disease is the leading cause of death in the
world
1 in 3 deaths in the U.S. is cardiovascular
326,200 OOH Cardiac Arrests treated by EMS
209,000 In Hospital Cardiac Arrests
Most victims will die without immediate and appropriate intervention
Why is this so important?
Slide20Survival rates in OHCA are improving (all rhythms)
Survival increase attributed (in part) to:
Increased emphasis and focus on CPR quality (Perfusion)
Systems of Care – Post arrest / post-resuscitation care
The good news…
Slide21Slide22Basic Life Support
CAB remains the focus (perfusion)
The Chain of Survival links in adults are unchanged
Emphasis on maximizing compressions
Ensuring
chest compressions of adequate rateEnsuring chest compressions of adequate depth
Allowing full chest recoil between compressionsMinimizing interruptions in chest compressions
Avoiding excessive ventilation
Slide23Basic Life Support
R
apid identification of cardiac arrest by dispatchers with bystander instructions
If the patient is unconscious with abnormal or absent breathing, it is reasonable for
dispatcher
to assume that the patient is in cardiac
arrestDispatchers
should provide chest compression-only CPR instructions to callers for adults with suspected
OHCA
(Weird one) For suspected
spinal injury, rescuers should initially use manual spinal motion restriction (
e.g.,
placing 1 hand on either side of the patient’s head to hold it still) rather than immobilization devices, because use of immobilization devices by lay rescuers may be
harmful
Slide24Basic Life Support
In
adult
cardiac arrest, it is
reasonable
to perform chest compressions at a rate
of 100/min to 120/min (note the new upper limit)
During manual CPR,
perform
chest compressions to a depth of at least 2
inches or
5 cm for an average adult, while avoiding excessive chest compression depths (greater than
2.4 inches
or 6 cm
)
Greater emphasis on minimizing pre and post shock pauses in compressions
Slide25Basic Life Support
In adult cardiac arrest with an unprotected airway,
perform
CPR with
the goal
of a chest compression fraction as high as possible, with a target of at least 60
%For witnessed OHCA with a shockable rhythm, it may be reasonable for EMS systems with
priority-based
,
multi-tiered
response to delay positive-pressure ventilation by using a strategy of up to 3 cycles of 200 continuous compressions with passive oxygen insufflation and airway
adjuncts
Slide26Basic Life Support
It is reasonable to
provide
opioid overdose response education with or without
naloxone distribution
to persons at risk for opioid overdose (or those living with or in frequent contact
with such persons
)
For
patients with known or suspected opioid overdose who have a definite pulse but no normal breathing or only gasping (
ie
, a respiratory arrest), in addition to providing standard BLS care, it is reasonable for appropriately trained BLS healthcare providers to administer IM or IN
naloxone
Slide27Basic Life Support
D
o
not recommend the routine use of passive ventilation techniques during conventional
CPR for adults
I
n EMS systems that use bundles of care involving continuous chest compressions,
the use
of passive ventilation techniques may be considered as part of that
bundle
There is insufficient evidence to recommend the use of artifact-filtering algorithms for analysis of ECG rhythm during CPR
Slide28Basic Life Support
When the victim has an advanced airway in place during CPR, rescuers no longer deliver cycles
of 30
compressions and 2
breaths. Instead
, it may be reasonable for the provider to deliver 1 breath every 6 seconds (10 breaths
per minute) while continuous chest compressions are being
performed
It may be reasonable to use audiovisual feedback devices during CPR for real-time optimization
of CPR performance
Slide29CPR Techniques & Devices
(2010 Guidelines)
“Alternatives to conventional manual CPR have been developed
in an effort to enhance perfusion during resuscitation from
cardiac arrest and to improve survival. Compared with conventional
CPR, these techniques and devices typically require more personnel, training, and equipment, or apply to a specific setting.
Some
alternative CPR techniques and devices may improve hemodynamics
or short-term survival when used by well-trained providers in
selected patients”.
Slide30CPR Techniques & Devices
(2015 Guidelines)
“Three
randomized clinical trials comparing the use of mechanical chest compression devices
with conventional
CPR have been published since the 2010 Guidelines.
None
of these studies
demonstrated superiority
of mechanical chest compressions over conventional CPR.
Manual
chest compressions
remain the
standard of care for the treatment of cardiac arrest, but mechanical chest compression devices may
be a
reasonable alternative for use by properly trained
personnel”.
Slide31CPR Techniques & Devices
(2015 Guidelines)
“The use of mechanical piston devices may be considered in specific settings where the delivery
of high-quality
manual compressions may be challenging or dangerous for the provider (
eg, limited rescuers available, prolonged CPR, during hypothermic cardiac arrest, in a moving ambulance,
in the angiography suite, during preparation for extracorporeal CPR [ECPR]), provided that rescuers strictly limit interruptions in CPR during deployment and removal of the devices.”.
Slide32CPR Techniques & Devices
ITD
The PRIMED
study (n=8718) failed to demonstrate improved outcomes with
the use
of an impedance threshold device (ITD) as an adjunct to
conventional CPR when compared with use of
a sham device. This negative high-quality study prompted a Class III: No Benefit
recommendation regarding
routine use of the ITD.
Slide33Advanced Cardiac
Life Support
“The foundation of successful ACLS is good BLS”
U
se
of the maximal feasible inspired oxygen during CPR
was strengthened
. This
recommendation
applies only while CPR is ongoing and does not apply to care
after ROSC
Physiologic
monitoring during CPR may
be useful
, but there has yet to be a clinical trial demonstrating that goal-directed CPR based on
physiologic parameters
improves
outcomes
Continuous waveform capnography remained a Class I recommendation for confirming placement of
an ETT
Slide34Advanced Cardiac
Life Support
The Class of Recommendation for use of standard dose epinephrine (1 mg every 3 to 5 minutes)
was unchanged
Vasopressin was removed from the ACLS Cardiac Arrest Algorithm as a vasopressor therapy
in recognition
of equivalence of effect with other available
interventions (epinephrine)
Recommendation
against the routine prehospital cooling of patients after ROSC by
using rapid
infusion of cold saline
Slide35Advanced Cardiac
Life Support
(Knowledge Gap)
More knowledge is needed about the impact on survival and neurologic outcome when
physiologic targets
and ultrasound are used to guide resuscitation during cardiac arrest.
The dose-response curve for defibrillation of shockable rhythms is unknown, and the initial shock energy, subsequent shock energies, and maximum shock energies for each waveform are unknown.
More information is needed to identify the ideal current delivery to the myocardium that will result
in defibrillation
, and the optimal way to deliver it. The selected energy is a poor comparator for
assessing different
waveforms, because impedance compensation and subtleties in waveform shape result in
a different transmyocardial current among devices at any given selected energy.
Slide36Advanced Cardiac
Life Support
(Knowledge Gap)
Is a hands-on defibrillation strategy with ongoing chest compressions superior to current
hands-off strategies
with pauses for defibrillation?
What is the dose-response effect of epinephrine during cardiac arrest?
The efficacy of bundled treatments, such as epinephrine, vasopressin, and steroids, should be evaluated
, and
further studies are warranted as to whether the bundle with synergistic effects or a single agent
is related
to any observed treatment
effect
.
Slide37Advanced Cardiac
Life Support
(Knowledge Gap)
There are no randomized trials for any antiarrhythmic drug as a second-line agent for refractory
ventricular fibrillation/pulseless
ventricular tachycardia, and there are no trials evaluating the initiation or
continuation of anti-
arrhythmics
in the post-cardiac arrest period.
Controlled clinical trials are needed to assess the clinical benefits of ECPR versus traditional CPR
for patients
with refractory cardiac arrest and to determine which populations would most benefit.
Slide38Systems of Care
Recognizes different needs between in hospital and out-of-hospital systems of care (all arrests are not created equal)
OHCA is usually unexpected
Focus on prevention for in hospital arrests
Given the low risk of harm and the potential benefit of such notifications, it may be reasonable
for communities
to incorporate, where available, social media technologies
for rescuers
who
are willing
and able to perform CPR and are in close proximity to a suspected victim of
OHCA
Slide39Systems of Care
Designated specialized cardiac arrest receiving centers (regional) may be beneficial
Public access defibrillation improves survival but is still not widely prevalent
Slide40Slide41The Ethics of Resuscitation
Most significant change is caution when prognosticating regarding neurologic outcome and survival, particularly due to:
The use of extracorporeal CPR (ECPR) for cardiac arrest
Targeted Temperature Management
Intra-arrest
prognostic factors for infants, children, and adults
Prognostication for newborns, infants, children, and adults after cardiac arrest
Encourages efforts to address organ / tissue donation
Slide42So?
Slide43e
ccguidelines.heart.org
Slide44Medtronic Foundation
Cardiac Arrest Playbook
http://www.medtronic.com/community-response-guide-2012/guide/
Slide45Medtronic Heart Rescue Program
Partnership
Slide46Slide47Survivors
Slide48Survivor Support
AMR has seen a steady rise in the number of survivors making them a top priority.
Partner Story: AMR
Resources for survivors:
Survivor Celebrations
Survivor Support Groups
Slide49Slide50Thanks…