ACLS Guidelines 2015

Wanda Rivera Bou MD, FAAEM, FACEP

Assistant Professor
Department of Emergency Medicine
University of Puerto Rico School of Medicine
AHA - ACLS National Faculty
 Disclosure Information
Wanda Rivera Bou, MD

I have no financial relationships with drug or

device manufacturing companies
Objectives: Will discuss

n Identify the ACLS 2015 science updates

n Describe the rationale for the science

updates

n Therapeutic interventions
International Liaison Committee on
Resuscitation
Highlights of the 2015 AHA Guidelines Update for CPR and ECC
New AHA Adult Chains of Survival

IN-HOSPITAL
(note new Surveillance
and Prevention link)

OUT OF HOSPITAL
Including EMS
Adult BLS and CPR Quality

n There is continued emphasis on the

characteristics of high-quality CPR:

l compressing the chest at an adequate rate and depth

l allowing complete chest recoil after each compression
l minimizing interruptions in compressions
l avoiding excessive ventilation
 Chest Compression Rate
n It is reasonable to perform compressions at a
rate of 100-120/min Metronome
Observational study
Dec, 2005 May, 2007
Sharp decline in survival
with rate > 140/min

Idris A.H et al, Circulation. 2012;125:3004-3012

Rapid Compression Rate can
Compromise Depth

Idris et al, Critical Care Medicine, 2015:43 (4): 840

 Chest Compression Depth
n Chest compression to at least 2 inches (5 cm),
avoiding chest compression depths > 2.4
inches (6 cm)
Small study: more injuries with
compressions greater than 2.4
inches (6cm).
(Hellevuo et al, Resuscitation, 2013)

Difficult to judge depth

without devices

Rescuers typically dont

push hard enough

Stiell I.G et al, Circulation. 2014;130:1962-1970

BLS for
HCP

Highlights of the 2015 AHA Guidelines Update for CPR and ECC
For BLS and ACLS algorithms, please referred to
http://eccguidelines.heart.org
Bystander CPR
Early CPR Increases Survival
Adult BLS and CPR Quality

n Minimizing interruptions with a goal of chest

compression fraction of at least 60%

n CCF = It is the percentage of time in which

chest compressions are done by rescuers
during a cardiac arrest

n Fewer pauses in CPR increase the chances of

surviving a cardiac arrest (less than 10 sec)
Ventilation During CPR with an
Advanced Airway

n It would be reasonable to deliver 1 breath

every 6 sec (10 breath/min)
ACLS Summary of Key Issues (New)
n Vasopressin and Epinephrine
n ETCO2 for Prediction of Fail Resuscitation
n Steroids (ICHA and OCHA)
n B-Adrenergic Blocking Drugs
n Lidocaine
n PCI
n ECMO
n Targeted Temperature Management
Vasopressin and Epinephrine

n Vasopressin was removed for simplicity

n No benefit of vasopressin over epinephrine

n Epinephrine - timing of administration

l It is reasonable to administer as soon as possible
after the onset of cardiac arrest due to an initial
nonshockable rhythm (PEA/Asystole)
ETCO2

n Low ETCO2 (< 10 mmHg) in intubated pts

after 20 mins of CPR is associated with a low
likelihood of resuscitation (shouldnt be used
in isolation)
Steroids

n There are no data to recommend for or

against the routine use alone for IHCA (Class
IIb, LOE C-LD)

n Uncertain benefit for OHCA

Post-Cardiac Arrest Drug Therapy:
New
n B-blocker
l There is inadequate evidence to support routine use
after cardiac arrest

n Lidocaine
l There is inadequate evidence to support the routine
use after cardiac arrest
PCI
n Should be performed emergently for OHCA pts
with suspected cardiac etiology and STEMI
(Class I, LOE B-NR)

n Reasonable for select pts after OHCA with

suspected cardiac etiology but w/o STE on ECG
(Class II a, LOE B-NR)

n Reasonable in post-cardiac arrest pts for whom

angiography is indicated regardless of whether
is comatose or awake (Class II a, LOE C-LD)
ECMO

n May be considered for select pts, in settings

where it can be rapidly implemented (Class
IIb, LOE C-LD)
Targeted Temperature
Management
n All comatose pts with ROSC should have a
TTM for at least 24 hrs
l TT between 32C-36C, maintained constantly
n Continuing TM beyond 24 hrs
l Is reasonable in comatose pts to actively prevent
fever
n Out of Hospital Cooling
l Not recommended
Nielsen N. et al, N Engl J Med. 2013;369:2197-2206
PROGNOSTICATION for poor
outcome USING CLINICAL EXAM

n The earliest time for prognostication in pts

treated with TTM, may be 72 hrs after return
of normothermia (Class II b, LOE C-EO)

n The earliest time for prognostication in pts not

treated with TTM is 72 hrs after cardiac arrest
(Class I, LOE B-NR)
Updated Recommendations:
Special Circumstances
n Naloxone administration in combination with
BLS care for opioid-associated life-threatening
emergencies

n Intravenous lipid emulsion considered for

treatment of local anesthetic systemic toxicity

n Refined recommendations regarding uterine

displacement for CPR during pregnancy
Take-Home Messages

n Lay provider care saves lives

n Defibrillation as early as possible
n Medications have modest benefit
n Advanced Airway is a lower priority early in
cardiogenic arrest
l If performed, dont interrupt more important
interventions (compressions, defibrillation)
Take-Home Messages

n Post-resuscitation care is a key component of

management
l Targeted Temperature Management
l Coronary Reperfusion

n Do not forget your basic critical care skills

wandabou@me.com