ACLS Guidelines 2010

The rules and

changes

Peter Cameron, MD
The Alfred Hospital/Monash
University
Melbourne, Australia

The New ACLS Guideline

Published online Oct 18 2010

Published in Circulation Nov 2 2010
Similar endorsements from
Australian/NZ/European and International
Resuscitation Councils

 1n 1960 Kouwenhoven & Knickerbocker - 14

patients survive arrest with CPR!
2 years later direct current defibrillator
introduced
1966 first AHA guidelines
2010 was the 50 anniversary of CPR

Smart People

356 resuscitation experts

29 countries
36 month period
411 scientific reviews

 the new recommendations do not imply

that care using past guidelines is either
unsafe or ineffective
still insufficient data to demonstrate that
any drugs or mechanical CPR devices
improve long-term outcome after cardiac
arrest

ACLS 2010 Guideline

Review

Basic Life Support (BLS)

Cardiac Arrest
Tachycardias
Bradycardias

BLS

BLS Principles DRS ABCD

No change to Dangers and Response
S Send for help
A open the Airway
B check Breathing but no need to deliver two rescue breaths
C perform 30 Compressions for victims who are unresponsive
and not breathing normally, followed by 2 breaths
D attach an AED as soon as it is available

BLS Principles DRS ABCD

Compressions before 2 initial rescue breaths
Signs of life changed to unresponsive and not breathing
normally
If unwilling / unable to perform rescue breathing, then perform
compression only CPR
New focus on maintenance of CPR quality change rescuers
every two minutes
Pulse check downgraded for HCPs unreliable indicator of
the need for resuscitation

BLS Compressions
One or two handed technique for children (Australian
Ambulance have adopted two)
Push to a depth of at least 5 cms at a rate of at least 100 /
min
Allow full recoil of chest between compressions
30 Compressions : 2 ventilations for all age groups (1 or 2
rescuer)
Apply AED (if available) now BLS skill taught as part of CPR
programs

BLS Health Professional (Cont)

CPR Rates:
Single Rescuer: 30 Compressions : 2 ventilations at a rate of >
100 per minute for all age groups (Approx 5 cycles every 2
minutes <18 seconds/cycle)
Two Rescuer: Adult 30:2 at rate of 100 per minute
Two Rescuer: Child (0-14) 15:2 at rate of 100 per minute
(Approx 10 cycles every 2 minutes)

Pause to allow ventilations (until intubated or LMA insitu)

BLS Health Professional (Cont)

AED - Apply and follow the prompts
Continue until signs of life briefly check (?pulse) every two
minutes (dont pause CPR for more than 10 seconds!!)
Change compressor every 2 minutes to avoid fatigue

AED
AED - Single shock strategy
2 minutes CPR before reanalysis
No need to reprogram energy levels should follow those
programmed by manufacturer for their specific device
Reasonable to continue to utilise older devices until replaced
as part of normal life cycle any resuscitation is better than
none

Choking (FBAO)

CPR Changes Emphasise

Push hard, push fast,

minimise interruptions; allow
full chest recoil, and dont
hyperventilate

Rationale
Although ventilations are impt part of
resuscitation, evidence shows that
compressions are the critical element in
adult resuscitation. In the A-B-C
sequence, compressions are often
delayed.
If a pulse is not detected within 10
seconds, do start compressions without
further delay.

Compression Depths
Compression depths are:
Adult- at least 2 inches (5cm)
Children- at least 1/3 the depth of the chest
(appx 2 inches (5cm)
Infants- at least 1/3 the depth of the chest,
approx 1 1/2 inches (4cm)

Airway & Breathing

Cricoid pressure is no longer routinely
recommended for use with ventilations
Randomized control trials demonstrated
cricoid pressure still allows for aspiration.
It is also difficult to train providers to
perform the maneuver correctly.

ALS Principles
To provide critical blood flow to the vital organs with high
quality chest compressions
Defibrillation as soon as possible provides the best chance of
survival in victims with VF or pulseless VT (cf. CPR prior to
defib)
Return of spontaneous circulation as rapidly as possible
Intensive care support aimed to achieve the best outcomes

ALS Principles Key revisions I

High quality chest compressions with minimal interruptions;
continuing compressions during defibrillator charging
Single (non-stacked) shocks, but stacked shocks may be
considered for HPC witnessed arrest*, during cardiac
catheterisation or after cardiac surgery
Precordial thump is de-emphasised
IV or IO drug administration (ETT de-emphasised)

*Where a monitor / defibrillator is connected at the time

ALS Principles Key revisions II

Adrenaline 1mg for VF/VT after the second shock once chest
compressions have restarted and then every 3-5 min (alternate
blocks of CPR)
Amiodarone 300mg after third shock
Atropine no longer recommended for routine use in asystole or
PEA
Less emphasis on early intubation
Capnography to confirm and continually monitor tracheal tube
placement, quality of CPR, and to provide early indication of ROSC

Post Resuscitation Care

Recognition that a post resuscitation care protocol may improve
survival following ROSC
Avoid hyperoxaemia oxygen titration to Sa02 94-98%
Primary PCI in appropriate patients with sustained ROSC
Normoglycaemic glucose control (BSL >10 mmol/l should be
treated but hypoglycaemia avoided)
Therapeutic hypothermia to include comotose survivors of
cardiac arrest of any rhythm

Single Shock Defibrillation

Strategy
Single shock strategy continues to be recommended to improve
outcome by reducing interruption of chest compressions
Monophasic 360J / Biphasic 200 J (Adult)
Monophasic / Biphasic 4J/kg (Paed)

Exception is health professional witnessed VF/VT.

Salvo of three stacked shocks (Mono 360J / Biphasic 200J; with
rhythm checks between shocks)
Followed by CPR and single shock strategy if unsuccessful

PLS Principles Key

revisions I
Recognition that HCPs cannot reliably determine the
presence of a pulse in < 10s.
Compress at least 1/3 AP diameter (Approx. 5cms in children
and 4cms in infants)
Defibrillation is a single shock of 4J/kg (mono or bi). Staked
shocks as per adult
IV or IO drug administration (ETT de-emphasised)
Cuffed tracheal tubes ok for short term

Newborn Resuscitation I
For uncomplicated babies, a delay in cord clamping of at least
one minute from delivery is recommended
For term infants, air should be used initially.
Recommended CV ratio remains 3:1
Very prem infants should be placed in / under a polyethylene
bag or sheet to the neck

Newborn Resuscitation II
Adrenaline IV dose 20-30 mcg/kg. (ET would require at least
50-100 mcg/kg to achieve a similar effect to 10 mcg/kg IV)
Infants with evolving moderate severe hypoxic ischaemic
encephalopathy should be treated with therapeutic
hypothermia following immediate resuscitation
Capnography most reliable method to confirm and continually
monitor tracheal tube placement in neonates with
spontaneous circulation

Defibrillation
AFIB cardioversion : Biphasic 120-200J
Monophasic 200J.
AFlutter cardioversion/SVT: 50-100J either
monophasic or biphasic.
If the initial cardioversion shock fails,
providers should increase the dose in a
stepwise fashion.

AED Use
Children 1-8yrs, pediatric dose attenuator
should be used if available. Otherwise,
standard AED may be used.
Infants (1<yr) a manual defibrillator is
preferred over above option.

 Stable monomorphic VT responds well to

monophasic or biphasic synchronized
shocks at 100J.
If no response to first shock, increase dose
in stepwise fashion.
Polymorphic VT is unstable as an arrest
rhythm and require unsynchronized
shocks.

V Fib
Shock 200 J every 2 minutes
CPR for 2 minutes while admin Rx
Ventilate, IV Epi, Amiodarone 300mg

The Rationale
True effective dose (lower or upper limit)
known but doses (4J/kg-9J/kg) have been
found to have no significant adverse
effects.

Give Oxygen when needed

Supplementary oxygen is not needed for pts without
evidence of respiratory distress or when
oxyhemoglobin saturation is >93%
EMS providers administer oxygen during the initial
assessment of pts with suspected ACS/ However,
there is insufficient evidence to support its routine
use in uncomplicated ACS. If the pt is dyspneic, is
hypoxemic, or has obvious signs of heart failure,
providers should titrate oxygen therapy to maintain
O2 sat >93%

Airway and Breathing

Continuous quantitative waveform
capnography is now recommended for
intubated pts throughout the periarrest
period. Useful in confirming ETT
placement and for monitoring CPR quality
and detected ROSC based on end tidal
CO2 values.

SUMMARY

Look, listen, feel - removed

Healthcare providers briefly check for breathing when checking
responsiveness to detect signs of cardiac arrest.
After delivery of 30 compressions, lone rescuers open the victims
airway and deliver 2 breaths.
Encourage hands only CPR for untrained
Continuous CPR for advanced providers
Do GREAT CPR
AND C-A-B - radical but rational!

CARDIAC ARREST
A few changes in emphasis

IV
provision of high-quality CPR and rapid
defibrillation are of primary importance and
drug administration is of secondary
importance
20ml Bolus after drug

IO Access
Reasonable to establish access if IV
access is not readily available

Emergence of Supraglottic
Devices
CPR more important than airway initially
Put in a supraglottic if intubation is going to
be hard
LMA
King LT

Capnography
100% sensitive and specific for tracheal
intubation
Helps count 8-10 breaths minute
Predictor of outcome

No Atropine in PEA/Asystole
Available evidence suggests that the
routine use of atropine during PEA or
asystole is unlikely to have a therapeutic
benefit

Drugs= Transcutaneous Pacing

It hurts!
No better than drugs
Ok to go from drugs to TV pacing
NOT ROUTINE in arrest

Seek Reversible Causes

5Hs
Hypoxia
Hypovolemia
Hyperacidosis
Hyperkalemia
Hypothemia
5Ts
Thrombus (MI)
Thrombus (PE)
Tension PTX
Toxins
Tamponade

Vasopressors
VF continues after epi and CPR vasopressor
Amiodarone is first line
Not proven to result in long term outcome
Lidocaine is useless also

Epinephrine

Never any evidence that it works!

Abstract 1: A Randomized placebo controlled trial of adrenaline
in cardiac arrest- the PACA trial
Conclusion: The use of adrenaline in cardiac arrest was
associated w significant increase in the proportion of pts
achieving ROSC however this improvement did not extend to
survival to hospital discharge. As our results are unable to rule
out a clinically meaningful benefit of adrenaline in terms of
survival to hospital discharge, further investigation into the post
resuscitation period for those achieving ROSC is required in
order to identify management strategies to improve survival.

SUMMARY

Atropine OUT for PEA/Asystole

CPR first and fast
Airway- supraglottic emerges
Still have amiodarone even though it dont
work
Hope lies in a reversible cause

Tachycardia

Pearl 1: Dont
cardiovert to sinus
rhythm

Pearl 2: Rates<150 dont usually

cause instability in normal healthy
hearts

Pearl 3: Many
arrhythmias caused by
hypoxia- Fix that first

Pearl 4: If unstable use electricity- except

narrow complex when adenosine may be
ok

Pearl 5: IF THEY ARE PRETTY

STABLE - GET A 12 LEAD ECG

Adenosine vs. CCB

More rapid and less severe side effects
than calcium blockers

Adenosine in Wide Complex

Tachycardia

recent evidence suggests that adenosine

is relatively safe for both treatment and
diagnosis

Adenosine
May be considered in the initial diagnosis
of stable, undifferentiated, regular,
monomorphic, wide-complex tachycardia.
Not to be used if the pattern is irregular.
New evidence of safety and potential
efficacy. Help diagnose and treat SVT with
aberrant conduction.

Caveats/Comments
Not for irregular or polymorphic
SVT should slow or convert
VT usually will not

Wide, Regular, Stable Other

Choices

Cardioversion, Procainamide, Amiodarone,

Sotalol
Generally only try one!
Procaine 20-50mg/hour (17mg/kg or QRS
50% narrowed, or hypotension)

Wide Complex Regular:

Amiodarone
An option- better than lidocaine
150 mg IV over 10 minutes Can repeat
2.2 g IV total in 24 hours

Wide Irregular Tachycardias

Atrial fibrillation - BBB
Atrial fib - accessory pathway
Polymorphic VT

Polymorphic VT
Defibrillation

3 Types of
Polymorphic
VT
Prolonged QT : Magnesium
Familial : IV Magnesium Pacing Betablockers No Isoprel
Ischemic: Amiodarone, BB,
revascularization

Tachycardia

Morphine
Morphine should be given with caution to
pts with unstable angina.
Morphine is indicated in STEMI when CP
unresponsive to nitrates.
Morphine found to be associated with an
increase mortality with angina and
unstable angina large registry.

BRADYCARDIA

Atropine
Atropine is not recommended for
PEA/Asystole.
Use of atropine unlikely to have a
therapeutic benefit

Atropine
First Dose-->0.5mg bolus
Repeat every 3-5 minutes
Max Dose 3mg

If Atropine Fails

Transcutaneous Pacing
or
Dopamine 2-10 mcg per minute
Epinephrine 2-10mcg per minute

When NOT to use Atropine

Cardiac Transplant- ineffective or brady
Wide complex Type 2 or 3 blocks

Chronotropic Drugs
For symptomatic or unstable bradycardia,
chronotropic drug infusion are
recommended as an alternative to pacing.
Epi, Dopamine acceptable alternative to
external transcutaneous pacing when
atropine is ineffective.

5 Reversible Causes of PEA

Hypoxia
Tension PTX
Hypovolemia
Cardiac Tamponade
Toxic-Metabolic

EMD- PEA 5 Step Management

Oxygenate and Ventilate

Secure IV Access
Look for 3 Causes (ECG, Temp, Vol status)
Epinephrine (1mg q 3mins)
Review all 5 causes

5 Possible Ultrasound Findings

Tamponde
Hypovolemia
Massive PE
Cardiogenic Shock
Normal->Lung view

Causes of PEA- 4 chamber view

Pericardial Effusion + RV
Strain=Tamponade
RV Strain=LV Strain=Hypovolemia
RV dil + RA dil vs LV Strain=PE
Poor contractility= Cardiogenic Shock
Nl = Lung view

Implementation
Current Guidelines still OK
Up to each organisation to determine when to implement
changes

Questions