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2015 Interim Resources for HeartCode ACLS - PDF
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1 2015 Interim Resources for HeartCode ACLS Original Release: November 25, 2015 Starting in 2016, new versions of American Heart Association online courses will be released to reflect the changes published in the 2015 AHA Guidelines Update for CPR and ECC. All current AHA courses remain valid and should continue to be used for training until the new versions are released. The release of new Guidelines does not mean that the use of earlier Guidelines is unsafe or ineffective. To ensure that students in current courses are aware of the changes in science, the following interim resources are available free of charge for HeartCode ACLS students: Highlights of the 2015 American Heart Association Guidelines Update for CPR and ECC (available at 2015ECCguidelines.heart.org): In-depth summary by topic of the changes to science and treatment recommendations published in the 2015 AHA Guidelines Update for CPR and ECC ACLS Provider Manual Comparison Chart (attached): Chart showing how science changes in the 2015 AHA Guidelines Update for CPR and ECC differ from current ACLS course content Interim ACLS 1-Rescuer Adult CPR and AED Checklist (attached): Checklist of critical performance steps updated with 2015 science changes
2 2015 Interim Training Materials ACLS Provider Manual Comparison Chart Assessment sequence (Part 2: The Systematic Approach, and Part 5: The Healthcare providers (HCPs) must call for nearby help upon finding the victim unresponsive, but it would be practical for an HCP to continue to assess the breathing and pulse simultaneously before fully activating the emergency response system (or calling for backup). BLS Changes The HCP should check for response while looking at the patient to determine if breathing is absent or not normal. The intent of the recommendation change is to minimize delay and to encourage fast, efficient, simultaneous assessment and response rather than a slow, methodical, step-by-step approach. These recommendations allow flexibility for activation of the emergency response system to better match the HCP s clinical setting. Trained rescuers are encouraged to simultaneously perform some steps (ie, checking for breathing and pulse at the same time), in an effort to reduce the time to first chest compression. Integrated teams of highly trained rescuers may use a choreographed approach that accomplishes multiple steps and assessments simultaneously rather than the sequential manner used by individual rescuers (eg, one ACLS Provider Manual Comparison Chart 1
3 Compression rate (Part 2: The Systematic Approach, and Part 5: The rescuer activates the emergency response system while another begins chest compressions, a third either provides ventilation or retrieves the bag-mask device for rescue breaths, and a fourth retrieves and sets up a defibrillator). In adult victims of cardiac arrest, it is reasonable for rescuers to perform chest compressions at a rate of 100 to 120/min. It is reasonable for lay rescuers and HCPs to perform chest compressions at a rate of at least 100/min. The minimum recommended compression rate remains 100/min. The upper limit rate of 120/min has been added because 1 large registry series suggested that as the compression rate increases to more than 120/min, compression depth decreases in a dose-dependent manner. For example, the proportion of compressions of inadequate depth was about 35% for a compression rate of 100 to 119/min but increased to inadequate depth in 50% of compressions when the compression rate was 120 to 139/min and to inadequate depth in 70% of compressions when the compression rate was more than 140/min. ACLS Provider Manual Comparison Chart 2
4 Chest compression depth (Part 2: The Systematic Approach, and Part 5: The Perform chest compressions to a depth of at least 2 inches/5 cm for an average adult. Avoid excessive chest compression depths of more than 2.4 inches/6 cm when a feedback device is available. The adult sternum should be depressed at least 2 inches (5 cm). A compression depth of approximately 5 cm is associated with greater likelihood of favorable outcomes compared with shallower compressions. While there is less evidence about whether there is an upper threshold beyond which compressions may be too deep, a recent very small study suggests potential injuries (none life-threatening) from excessive chest compression depth (greater than 2.4 inches/6 cm). Compression depth may be difficult to judge without use of feedback devices, and identification of upper limits of compression depth may be challenging. It is important for rescuers to know that chest compression depth is more often too shallow than too deep. ACLS Provider Manual Comparison Chart 3
5 Advanced airway ventilation rate Targeted temperature management 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 (ie, during CPR with an advanced airway). All comatose (ie, lacking meaningful response to verbal commands) adult patients with return of spontaneous circulation (ROSC) after cardiac arrest should have targeted temperature management (TTM), with a target temperature between 32 C and 36 C selected and achieved, and then maintained constantly for at least 24 hours. ACLS Changes When an advanced airway (ie, endotracheal tube, Combitube, or laryngeal mask airway) is in place during 2-person CPR, give 1 breath every 6 to 8 seconds without attempting to synchronize breaths between compressions (this will result in delivery of 8 to 10 breaths per minute). Comatose (ie, lacking meaningful response to verbal commands) adult patients with ROSC after out-ofhospital ventricular fibrillation cardiac arrest should be cooled to 32 C to 34 C for 12 to 24 hours. Induced hypothermia also may be considered for comatose adult patients with ROSC after IHCA of any initial rhythm or after OHCA with an initial rhythm of pulseless electrical activity or asystole. This simple single rate rather than a range of breaths per minute should be easier to learn, remember, and perform. Initial studies of TTM examined cooling to temperatures between 32 C and 34 C compared with no well-defined TTM and found improvement in neurologic outcome for those in whom hypothermia was induced. A recent high-quality study compared temperature management at 36 C and at 33 C and found outcomes to be similar for both. Taken together, the initial studies suggest that TTM is beneficial, so the recommendation remains to select a single target temperature and perform TTM. Given that 33 C is no better than 36 C, clinicians can select from a wider range of target temperatures. The selected temperature may be determined by clinician preference or clinical factors. ACLS Provider Manual Comparison Chart 4
6 Out-of-hospital cooling Vasopressors for resuscitation: vasopressin Vasopressors for resuscitation: epinephrine The routine prehospital cooling of patients with rapid infusion of cold intravenous (IV) fluids after ROSC is not recommended. Vasopressin in combination with epinephrine offers no advantage as a substitute for standard-dose epinephrine in cardiac arrest. It may be reasonable to administer epinephrine as soon as feasible after the onset of cardiac arrest due to an initial nonshockable rhythm. Comatose (ie, lacking meaningful response to verbal commands) adult patients with ROSC after out-ofhospital ventricular fibrillation cardiac arrest should be cooled to 32 C to 34 C for 12 to 24 hours. Induced hypothermia also may be considered for comatose adult patients with ROSC after IHCA of any initial rhythm or after OHCA with an initial rhythm of pulseless electrical activity or asystole. Pharmacology Changes One dose of vasopressin 40 units IV/intraosseously may replace either the first or second dose of epinephrine in the treatment of cardiac arrest. Epinephrine should be given for pulseless cardiac arrest. Before 2010, cooling patients in the prehospital setting had not been extensively evaluated. It had been assumed that earlier initiation of cooling might provide added benefits and also that prehospital initiation might facilitate and encourage continued in-hospital cooling. Recently published high-quality studies demonstrated no benefit to prehospital cooling and also identified potential complications when using cold IV fluids for prehospital cooling. Both epinephrine and vasopressin administration during cardiac arrest have been shown to improve ROSC. Review of the available evidence shows that efficacy of the 2 drugs is similar and that there is no demonstrable benefit from administering both epinephrine and vasopressin as compared with epinephrine alone. In the interest of simplicity, vasopressin has been removed from the Adult Cardiac Arrest Algorithm. A very large observational study of cardiac arrest with nonshockable rhythm compared epinephrine given at 1 to 3 minutes with epinephrine given at 3 later time intervals (4 to 6, 7 to 9, and greater than 9 minutes). The study found an association between early administration of epinephrine and increased ROSC, survival to hospital discharge, and neurologically intact survival. ACLS Provider Manual Comparison Chart 5
7 ACLS Course 2015 Interim Tool CPR and AED Skills Test 1-Rescuer Adult CPR and AED Checklist Student Name: Test Date: Skill Step BLS Survey and Interventions Critical Performance Steps if done correctly 1 Checks for responsiveness: Taps and shouts, Are you all right? 2 Yells for help, activates the emergency response system, and sends for an AED 3 Checks breathing and pulse (breathing and pulse check can be performed simultaneously; minimum 5 seconds, maximum 10 seconds) 4 Bares patient s chest and locates CPR hand position 5 Delivers first cycle of compressions at correct rate: 100 to 120/min (delivers 30 chest compressions in no less than 15 and no more than 18 seconds) 6 Gives 2 breaths (1 second each) AED Arrives AED 1 AED 2 AED 3 Turns AED on, selects proper pads, and places pads correctly Clears patient to analyze (must be visible and verbal check) Clears patient to shock/presses shock button (must be visible and verbal check; maximum time from AED arrival less than 45 seconds) Student Continues CPR 7 Delivers second cycle of compressions at correct hand position (acceptable: greater than 23 of 30 compressions) 8 Gives 2 breaths (1 second each) with visible chest rise The next step is performed only if the manikin is equipped with a feedback device, such as a clicker or light. If there is no feedback device, STOP THE TEST. 9 Delivers third cycle of compressions of adequate depth with complete chest recoil (acceptable: greater than 23 compressions) STOP TEST Test Results Circle P or NR to Indicate Pass or Needs Remediation: P NR Instructor signature affirms that skills tests were done according to AHA Guidelines. Save this sheet with course record. Instructor Signature: Print Instructor Name: Date:
2015 AHA Guidelines for CPR and ECC: Time for a Change Michael Sayre, MD University of Washington Emergency Medicine. Disclosures
2015 AHA Guidelines for CPR and ECC: Time for a Change Michael Sayre, MD University of Washington Emergency Medicine Disclosures Medtronic Foundation: Research Grant Physio Control: EMS Fellowship Program