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The New Advanced Cardiac Life Support Guidelines: Implementing with Precision and Quality! Robert W. Neumar, MD, PhD University of Michigan Medical School
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Robert W. Neumar, MD, PhD The New Advanced Cardiac Life Support Guidelines: Implementing with Precision and Quality! FINANCIAL DISCLOSURE: Research Support: NIH and PhysioControl UNLABELED/UNAPPROVED USES DISCLOSURE: Use of devices for post-cardiac arrest hypothermic targeted temperature management is not approved by FDA Presenter Disclosure Information
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http://ECCGuidelines.heart.org
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New Chains of Survival http://ECCGuidelines.heart.org
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2015 ACLS Highlights CPR adjuncts Impedance threshold device (ITD) Active compression-decompression (ACD) Mechanical CPR CPR pharmacology Vasopressors Physiologic monitoring during CPR Focused ultrasound during CPR Extracorporeal CPR (ECPR) Post-cardiac arrest coronary angiography and PCI Post-cardiac arrest targeted temperature management Post-cardiac arrest neuroprognostication
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2015 ACLS Highlights CPR adjuncts Impedance threshold device (ITD) Active compression-decompression (ACD) Mechanical CPR CPR pharmacology Vasopressors Physiologic monitoring during CPR Focused ultrasound during CPR Extracorporeal CPR (ECPR) Post-cardiac arrest coronary angiography and PCI Post-cardiac arrest targeted temperature management Post-cardiac arrest neuroprognostication
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Impedance Threshold Device (ITD) and Active Compression Decompression (ACD) ACD ITD
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Impedance Threshold Device (ITD) and Active Compression Decompression (ACD) Survival with Good Neurologic Function (mRS ≤3) Aufderheide NEJM 2011 Frascone Resus 2013 p=0.027
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2015 AHA ECC Treatment Recommendations The routine use of the ITD as an adjunct during conventional CPR is not recommended. (Class III: No Benefit, LOE A) There is insufficient evidence to recommend for or against the routine use of ACD-CPR. ACD-CPR may be considered for use when providers are adequately trained and monitored. (Class IIb, LOE B) The combination of ITD + ACD CPR may be a reasonable alternative to conventional CPR with available equipment and properly trained personnel. (Class IIb, LOE C-LD) http://ECCGuidelines.heart.org
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2015 ACLS Highlights CPR adjuncts Impedance threshold device (ITD) Active compression-decompression (ACD) Mechanical CPR CPR pharmacology Vasopressors Physiologic monitoring during CPR Focused ultrasound during CPR Extracorporeal CPR (ECPR) Post-cardiac arrest coronary angiography and PCI Post-cardiac arrest targeted temperature management Post-cardiac arrest neuroprognostication
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Mechanical CPR Load Distributing Band Mechanical Piston
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Mechanical CPR Survival with Good Neurologic Function (mRS ≤3 or CPC 1-2) Wik Resus 2014 Rubertsson JAMA 2014 Hallstrom JAMA 2006 Perkins Lancet 2015
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2015 AHA ECC Treatment Recommendations Manual chest compressions remain the standard of care for the treatment of cardiac arrest, but mechanical piston and load distributing band devices may be a reasonable alternative for use by properly trained personnel. (Class IIb, LOE B-R) The use of mechanical piston or load distributing band 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. (Class IIb, LOE C-EO) http://ECCGuidelines.heart.org
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2015 ACLS Highlights CPR adjuncts Impedance threshold device (ITD) Active compression-decompression (ACD) Mechanical CPR CPR pharmacology Vasopressors Physiologic monitoring during CPR Focused ultrasound during CPR Extracorporeal CPR (ECPR) Post-cardiac arrest coronary angiography and PCI Post-cardiac arrest targeted temperature management Post-cardiac arrest neuroprognostication
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Study not adequately powered Standard-Dose Epinephrine Jacobs Resus 2011
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High-Dose Epinephrine Gueugniaud PY. NEJM 1998
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Time to First Epinephrine Dose Donnino BMJ 2015
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2015 AHA ECC Treatment Recommendation Standard dose epinephrine (one mg every 3 to 5 minutes) may be reasonable for patients in cardiac arrest (Class IIb, LOE B-R). High dose epinephrine is not recommended for routine use in cardiac arrest (Class III: No Benefit, LOE B-R). 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, LOE C-LD). http://ECCGuidelines.heart.org
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Vasopressin offers no advantage as a substitute for epinephrine in cardiac arrest (Class IIb, LOE B-R). The removal of vasopressin has been noted in the Adult Cardiac Arrest Algorithm―2015 Update. Vasopressin in combination with epinephrine offers no advantage as a substitute for SDE in cardiac arrest (Class IIb, LOE B-R). 2015 AHA ECC Treatment Recommendation http://ECCGuidelines.heart.org
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2015 ACLS Highlights CPR adjuncts Impedance threshold device (ITD) Active compression-decompression (ACD) Mechanical CPR CPR pharmacology Vasopressors Physiologic monitoring during CPR Focused ultrasound during CPR Extracorporeal CPR (ECPR) Post-cardiac arrest coronary angiography and PCI Post-cardiac arrest targeted temperature management Post-cardiac arrest neuroprognostication
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Physiologic Monitoring During CPR 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, LOE C-EO).
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End-Tidal CO2 Prognostication during CPR Levine NEJM 1998
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End-Tidal CO2 Prognostication during CPR 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 it should not be used in isolation (Class IIb, LOE C-LD). The above recommendation is made with respect to ETCO2 in patients who are with endotracheal intubation. In nonintubated patients, a specific ETCO2 cutoff value at any time during CPR should not be used as an indication to end resuscitative efforts (Class III: Harm, LOE C-EO).
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2015 ACLS Highlights CPR adjuncts Impedance threshold device (ITD) Active compression-decompression (ACD) Mechanical CPR CPR pharmacology Vasopressors Physiologic monitoring during CPR Focused ultrasound during CPR Extracorporeal CPR (ECPR) Post-cardiac arrest coronary angiography and PCI Post-cardiac arrest targeted temperature management Post-cardiac arrest neuroprognostication
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Cardiac Ultrasound During Cardiac Arrest Hernandez Resuscitation 2008
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Ultrasound Guided Resuscitation Strategy Hernandez Resuscitation 2008
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2015 AHA ECC Treatment Recommendation 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). 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 (Class IIb, LOE C-EO). http://ECCGuidelines.heart.org
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2015 ACLS Highlights CPR adjuncts Impedance threshold device (ITD) Active compression-decompression (ACD) Mechanical CPR CPR pharmacology Vasopressors Physiologic monitoring during CPR Focused ultrasound during CPR Extracorporeal CPR (ECPR) Post-cardiac arrest coronary angiography and PCI Post-cardiac arrest targeted temperature management Post-cardiac arrest neuroprognostication
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Extracorporeal Cardiopulmonary Resuscitation (ECPR) Percutaneous veno-arterial extracorporeal membrane oxygenation (VA-ECMO) during cardiac arrest
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Extracorporeal Cardiopulmonary Resuscitation (ECPR) Stub Resuscitation 2014
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2015 AHA ECC Treatment Recommendation 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 patients for whom the suspected etiology of the cardiac arrest is potentially reversible during a limited period of mechanical cardiorespiratory support. (Class IIb, LOE C-LD) http://ECCGuidelines.heart.org
Slide 33-

2015 ACLS Highlights CPR adjuncts Impedance threshold device (ITD) Active compression-decompression (ACD) Mechanical CPR CPR pharmacology Vasopressors Physiologic monitoring during CPR Focused ultrasound during CPR Extracorporeal CPR (ECPR) Post-cardiac arrest coronary angiography and PCI Post-cardiac arrest targeted temperature management Post-cardiac arrest neuroprognostication
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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, LOE B-NR). Consistent with all other STEMI care Neurological outcomes are unknowable at time of decision Many observational studies showing high rates of good outcome after PCI, and association of successful PCI with better outcomes 2015 AHA ECC Treatment Recommendation http://ECCGuidelines.heart.org
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Post-Cardiac Arrest NSTEMI Non ST Elevation Kern 2012 JACC
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Dumas, Cardiovasc Interv, 2010 Post-Cardiac Arrest NSTEMI
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Successful PCI Associated With Improved Post-Cardiac Arrest Outcome With or Without STEMI Dumas, Cardiovasc Interv, 2010
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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 (Class IIa, LOE B-NR). 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, LOE C-LD). 2015 AHA ECC Treatment Recommendation http://ECCGuidelines.heart.org
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2015 ACLS Highlights CPR adjuncts Impedance threshold device (ITD) Active compression-decompression (ACD) Mechanical CPR CPR pharmacology Vasopressors Physiologic monitoring during CPR Focused ultrasound during CPR Extracorporeal CPR (ECPR) Post-cardiac arrest coronary angiography and PCI Post-cardiac arrest targeted temperature management Post-cardiac arrest neuroprognostication
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Optimizing Therapeutic Hypothermia How cold? How soon? How long? Rewarming rate?
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Optimizing Therapeutic Hypothermia How cold? How soon? How long? Rewarming rate?
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What is the optimal target temperature? Out-of-hospital cardiac arrest of presumed cardiac etiology All initial rhythms except asystole if unwitnessed Comatose with ROSC for at least 20 minutes. Prospectively randomized to 33 or 36 °C x 28 hours Primary outcome: All cause mortality at end of trial 939 total patients Nielsen NEJM 2013
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TTM Trial Temperature Curves Nielsen NEJM 2013
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No Difference in Outcomes with Target Temperature of 33°C vs. 36°C Nielsen NEJM 2013
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Nielsen NEJM 2013 No Difference in Outcomes with Target Temperature of 33°C vs. 36°C
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Out-of-hospital cardiac arrest All presenting rhythms Comatose with ROSC for at least 20 minutes. Prospectively randomized to receive 2 L 4°C IV saline in ambulance vs. standard therapy Primary outcome: Survival and neurologic status at hospital discharge 1359 total patients Kim, JAMA 2014 How Soon Should Cooling be Started?
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Pre-Hospital Initiation of Cooling using Cold IV Saline Does Not Improve Outcomes Kim, JAMA 2014
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Increased Complications With Pre-Hospital Initiation of Cooling using Cold IV Saline Kim, JAMA 2014
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TTM recommended for all patients (ie VF/PEA/Asytole/IHCA/OOHCA) who remain comatose following ROSC from cardiac arrest (Class I, LOE B-R for VF/VT OHCA; Class I, LOE C-EO for non-VF/VT) TTM: select, maintain (for at least 24 hours) constant temperature between 32°C and 36°C. (Class I, LOE B-R) If patient still comatose: continue TTM beyond 24 hours by actively preventing fever. (Class IIa, LOE C-EO) Routine prehospital cooling of patients with rapid infusion of cold IV fluids is not recommended (no benefit, possible complications). (Class III: No Benefit, LOE A) http://ECCGuidelines.heart.org 2015 AHA ECC Treatment Recommendation http://ECCGuidelines.heart.org
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2015 ACLS Highlights CPR adjuncts Impedance threshold device (ITD) Active compression-decompression (ACD) Mechanical CPR CPR pharmacology Vasopressors Physiologic monitoring during CPR Focused ultrasound during CPR Extracorporeal CPR (ECPR) Post-cardiac arrest coronary angiography and PCI Post-cardiac arrest targeted temperature management Post-cardiac arrest neuroprognostication
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The earliest time to prognosticate a poor neurologic outcome using clinical examination in patients not treated with TTM is 72 hours after cardiac arrest (Class I, LOE B-NR). Can be even longer than 72 hours after cardiac arrest if the residual effect of sedation or paralysis confounds the clinical examination (Class IIa, LOE C-LD). 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 (Class IIb, LOE C-EO). 2015 AHA ECC Treatment Recommendation http://ECCGuidelines.heart.org
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Summary ITD alone not recommended but ITD+ACD CPR may improve outcomes Mechanical CPR not superior to manual CPR Epinephrine unchanged and vasopressin removed from algorithm Prospectively validated physiologic goals are needed for goal-directed CPR End Tidal CO2 <10 mmHg after 20 min of CPR indicator of futility Potential role for focused ultrasound, but remains unproven Growing evidence supporting ECPR but clinical trials are needed Early post-arrest coronary angiography and PCI (if indicate) recommended for STEMI and NSTEMI. Widened therapeutic range for hypothermic TTM and pre-hospital cooling with cold IV saline not recommended Reliability of early neuroprognostication remains limited