Interactive with ACLS! Reviewing the Basics and a 2015 … · Interactive with ACLS! Reviewing the...
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Interactive with ACLS!
Reviewing the Basics and a 2015
Update
Dan Israel, PharmD
Nick Wolters, PharmD
April 22, 2016
Grandview Medical Center: Dayton, OH
Objectives
• Describe the pharmacist’s role in code response
• Review pharmacotherapy treatment options in ACLS
• Summarize key changes in the 2015 AHA Guidelines for CPR and ECC
• Review key pharmacologic components of crash carts
Pharmacist Role in Code Response
• Lower mortality when part of
CPR teams
• Roles
– Medication dosing
– Medication procurement &
preparation
– Critical thinking
Bond et al. Clinical pharmacy services and hospital mortality rates. Pharmacotherapy. 1999 May;19(5):556-64
www.mayo.edu/mshs/careers/pharmacy/pha
rmacy-practice-residency-in-emergency-
medicine-minnesota
TERMS
• ROSC – Return of Spontaneous Circulation
• OHCA – Outside Hospital Cardiac Arrest
• VT/VF – Ventricular Tachycardia/Ventricular Fibrillation
• CPR – Cardiopulmonary Resuscitation
ACLS Cardiac Arrest Algorithm.
Robert W. Neumar et al. Circulation. 2010;122:S729-S767
Copyright © American Heart Association, Inc. All rights reserved.
Adult Cardiac Arrest Algorithm―2015 Update.
Mark S. Link et al. Circulation. 2015;132:S444-S464
Copyright © American Heart Association, Inc. All rights reserved.
“Evolutionary, not
revolutionary”
Patient Case
• Tragedy strikes
– A pharmacy resident, functioning on caffeine,
anxiety, and stress starts to feel “funny”
– Walks from his office to the ED… I don’t feel so
good…
“A turn for the worse”
• Suddenly Dan becomes unresponsive….
• A quick look to the monitor shows:
CODE BLUE!!!
The Code
• What should the team do now?
A. One round (30:2) of CPR
B. Defibrillate at 200 J for biphasic shock
C. Give 1 dose of Epinephrine 1mg IV
SHOCK HIM!!!
• 2015 re-emphasis: Shock first if AED
immediately available and shockable rhythm
analyzed, otherwise start CPR first
• Rationale: Survival benefit from defibrillation
is time dependent
Larsen MP, Eisenberg M, Cummins RO, Hallstrom AP. Predicting Survival from out-of-hospital cardiac arrest: a graphic
model. Ann Emerg Med 1993; 22:1652-1658.
Adult Cardiac Arrest Algorithm―2015 Update.
Mark S. Link et al. Circulation. 2015;132:S444-S464
Copyright © American Heart Association, Inc. All rights reserved.
“Evolutionary, not
revolutionary”
Chest Compression Rate
• 2010: “It is reasonable for lay rescuers and
HCPs to perform chest compressions at a rate
of at least 100 beats/min”
• 2015: “In adult victims or cardiac arrest, it is
reasonable for rescuers to perform chest
compressions at a rate of 100 – 120
beats/min”
Kleinman ME, et al. Part 5: Adult Basic Life Support and Cardiopulmonary Resuscitation Quality 2015 American Heart Association Guidelines
Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132[suppl 2]:S414–S435
Chest Compression Rate• 10,371 patients with OHCA
• ROSC in 34% patients – 9% survived until hospital
discharge
Idris AH, et al. Chest compression rate and survival following out-of-hospital cardiac arrest. Crit Care Med. 2015 Apr;43(4):840-8
ROSC Survival to Discharge
Rate Categories
(compressions/min)OR (95% CI) p OR (95% CI) p
<80 (n=335) 0.97 (0.74–1.27) 0.811 0.89 (0.53–1.50) 0.659
80-99 (n=1,933) 0.99 (0.86–1.13) 0.841 0.73 (0.57–0.93) 0.011
100-119 (n=2,932) Reference group Reference group
120-139 (n=955) 0.98 (0.82–1.16) 0.781 0.63 (0.45–0.88) 0.007
>140 (n=244) 1.08 (0.79–1.47) 0.640 0.95 (0.53–1.70) 0.864
Adjusted model (including compression depth and fraction) n=6,399
Chest Compression Rate
• Reduction in quality chest compressions
– Proportion of compressions <1.5in (38mm)
• 100 – 119 beats/min: 35%
• 120 – 139 beats/min: 50%
• >140 beats/min: 70%
Idris AH, et al. Chest compression rate and survival following out-of-hospital cardiac arrest. Crit Care Med. 2015 Apr;43(4):840-8
Chest Compression Depth
• 2010: “The adult sternum should be
depressed at least 2 inches”
• 2015: “During manual CPR, rescuers should
perform chest compressions to a depth of at
least 2 inches (5cm) for an average adult,
while avoiding excessive chest compression
depths (>2.4in)”
Kleinman ME, et al. Part 5: Adult Basic Life Support and Cardiopulmonary Resuscitation Quality 2015 American Heart Association Guidelines
Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132[suppl 2]:S414–S435
Chest Compression Depth
• 9,136 patients with OHCA
40.3mm55.3mm
Maximum survival was
in the depth interval of
40.3 – 55.3mm
Stiell et al. What Is the Optimal Chest Compression Depth During Out of-Hospital
Cardiac Arrest Resuscitation of Adult Patients? Circulation. 2014;130:1962-1970
Chest Compression Depth• 170 adult resuscitated patients
– Recorded compression quality; compared to chest CT or Xray during post-resuscitation care
– 32% (n=54 had sustained injuries)
• Mainly rib and sternal fractures
– Compression Depth (% injured)
• <50mm - 28%
• 50-60mm – 27%
• >60mm – 49%
Hellevuo H, Sainio M, Nevalainen R, Huhtala H, Olkkola KT, Tenhunen J, Hoppu S. Deeper chest
compression - more complications for cardiac arrest patients? Resuscitation. 2013;84:760–765
THE CODE CONTINUES
Adult Cardiac Arrest Algorithm―2015 Update.
Mark S. Link et al. Circulation. 2015;132:S444-S464
Copyright © American Heart Association, Inc. All rights reserved.
“Evolutionary, not
revolutionary”
Adult Cardiac Arrest: Vasopressors
• 2010: “One dose of vasopressin 40 units IV/ IO
may replace either the first or second dose of
epinephrine in the treatment of cardiac arrest”
• 2015: “Vasopressin in combination with
epinephrine offers no advantage as a substitute
for standard-dose epinephrine in cardiac arrest”
Link MS, et al. Part 7: Adult Advanced Cardiovascular Life Support 2015 American Heart Association Guidelines Update for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132:S444–S464.
Vasopressin versus epinephrine
Mukoyama, et al.
R
Patients with out of
hospital cardiac
arrest
Epinephrine 1mg q5-10mins
(max 4mg) n=158
Vasopressin 40 IU q5-10
mins (max: 160 IU) n=178
Prospective randomized control (Tokyo, Japan)
Primary End Point: survival to hospital discharge; ROSC; 24-h survival
Mukoyama T, Kinoshita K, Nagao K, Tanjoh K. Reduced effectiveness of vasopressin in repeated doses for patients
undergoing prolonged cardiopulmonary resuscitation. Resuscitation. 2009;80:755–761
Mukoyama, et al. study
• Outcomes
Outcome Vasopressin Epinephrine P-Value
ROSC 51 (28%) 42 (26.6%) 0.762
24-h survival 30 (16.9%) 32 (20.3%) 0.423
Survival to
discharge
10 (5.6%) 6 (3.8%) 0.431
Mukoyama T, Kinoshita K, Nagao K, Tanjoh K. Reduced effectiveness of vasopressin in repeated doses for patients
undergoing prolonged cardiopulmonary resuscitation. Resuscitation. 2009;80:755–761
Combination: Vasopressin vs
Epinephrine
R
Epinephrine 1mg
PLUS
standard of care*
n= 353
Vasopressin 40 IU
PLUS
Standard of care*
n= 374
Randomized double blind control trial (Singapore)
Primary End Point: survival to hospital discharge; ROSC;
Ong ME, et al. Resuscitation. 2012;83:953–960.
Patients with out of
hospital cardiac
arrest
*Meaning 2005 ACLS guidelines
(Epinephrine 1mg given ~95% after study drug)
Combination study
• Outcomes
• No difference in cerebral performance category at 30 days and 1 year post arrest
Outcome Epinephrine Vasopressin Adjusted P-
Value
ROSC 106 (30%) 119 (31.8%) 0.331
Survival to admission 59 (16.7%) 83 (22.2%) 0.051
Survival to discharge
or 30 days post arrest
8 (2.3%) 11 (2.9%) 0.271
Ong ME, Tiah L, Leong BS, et al. A randomised, double-blind, multi-centre trial comparing vasopressin and adrenaline in
patients with cardiac arrest presenting to or in the Emergency Department. Resuscitation. 2012;83:953–960.
NEJM: Vasopressin vs Epinephrine
R
Epinephrine 1mg PLUS
Vasopressin 40 IU
n= 1442
Epinephrine 1mg
PLUS
Placebo
n= 1452
Randomized double blind control trial
Primary End Point: survival to hospital discharge; ROSC;
Patients with out of
hospital cardiac
arrest
Gueugniaud PY, David JS, Chanzy E, et al. Vasopressin and epinephrine vs. epinephrine alone in cardiopulmonary
resuscitation. N Engl J Med. 2008;359:21–30.
NEJM combination study
• Outcomes
Outcome Combination Epinephrine
only
P-Value
ROSC 413 (28.6%) 428 (29.5%) 0.62
Survival to admission 299 (20.7%) 310 (21.3%) 0.69
Survival to discharge 24 (1.7%) 33 (2.3%) 0.24
1-year survival 18 (1.3%) 30 (2.1%) 0.09
Good neurologic
recovery at discharge
9 (37.5%) 17 (51.5%) 0.29
Gueugniaud PY, David JS, Chanzy E, et al. Vasopressin and epinephrine vs. epinephrine alone in cardiopulmonary
resuscitation. N Engl J Med. 2008;359:21–30.
Vasopressor Summary
• Vasopressin offers no advantage as a substitute or in combination with epinephrine
• Vasopressin has been removed from the ACLS 2015 adult cardiac arrest algorithm to simplify ACLS regimen
• Epinephrine is the catecholamine/vasopressorof choice in adult cardiac arrest
Link MS, et al. Part 7: Adult Advanced Cardiovascular Life Support 2015 American Heart Association Guidelines Update for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132:S444–S464.
ROSC
I got a pulse!!
http://www.rcrmctraining.org/job_education/alaris/etco2/t1
/p04.htm
Lidocaine after ROSC
• 2010: Not recommended
• 2015: “Currently inadequate evidence to
support the routine use of lidocaine after
cardiac arrest. However, the initiation or
continuation of lidocaine may be considered
immediately after ROSC from cardiac arrest
due to VF/pVT”
Link MS, et al. Part 7: Adult Advanced Cardiovascular Life Support 2015 American Heart Association Guidelines Update for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132:S444–S464.
Lidocaine after ROSC
• Retrospective multi-variate cohort analysis
• Study Group: Witnessed OHCA due to VT/VF
• Intervention: Lidocaine upon first documented
ROSC in absence of VT/VF
– Primary outcome:
• Re-arrest from recurrent VF/VT after initial ROSC,
• Admission to hospital,
• Survival to hospital discharge
Kudenchuk PJ, Newell C, White L, et al. Prophylactic lidocaine for post resuscitation care of patients with out-of-hospital
ventricular fibrillation cardiac arrest. Resuscitation. 2013;84:1512–1518
• Limitations
– Lidocaine group: shorter time from EMS dispatch to ROSC (18.6 mins vs. 25.2 mins; P<0.001)
– Independent association (not-causal)
Outcomes Lidocaine
(N=1296)
Non-recipients
(N=425)
Re-arrests 19.9% 45.2% P<0.0001
Shocks over course of
resuscitation
4.3 + 3.9 6.6 + 5.7 P<0.0001
Epinephrine required
after ROSC
13.1% 27.1% P<0.0001
Survived to admission 93.5% 84.9% P<0.0001
Survived to discharge 62.4% 44.5% P<0.0001
Kudenchuk PJ, Newell C, White L, et al. Prophylactic lidocaine for post resuscitation care of patients with out-of-hospital
ventricular fibrillation cardiac arrest. Resuscitation. 2013;84:1512–1518
Half way there…Living on a prayer?
• Patient is unresponsive…
Targeted Temperature Management
• 2010: “comatose adult patients with ROSC after out-of-hospital VF cardiac arrest should be cooled to 32C to 34C for 12-24 hours. Induced hypothermia also may be considered for comatose adult patients with ROSC after IHCA (In-Hospital Cardiac Arrest) of any initial rhythm or after OHCA with an initial rhythm of pulseless electrical activity or asystole”
• 2015: “all comatose patients with ROSC after cardiac arrest should have TTM, with a target temperature between 32-36 selected and achieved, then maintained constantly for 24 hours”
• 2015: “Recommend AGAINST the use of routine prehospitalcooling of patients after ROSC with rapid infusion of cold IV fluids”
Callaway et al. Part 8: Post–Cardiac Arrest Care 2015 American Heart Association Guidelines Update for
Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(suppl 2):S465–S482
Targeted Temperature Management
• 936 patients with OHCA
– 33°C – 473 patients
• 235 died (50%)
– 36°C – 466 patients
• 225 died (48%)
Nielsen et al. Targeted Temperature Management at 33°C versus 36°C after Cardiac Arrest. N Engl J Med 2013;369:2197-206
Targeted Temperature Management
• Pre-hospital cooling– Kim et al.
• Found an increase in pulmonary edema and re-arrest among patients treated with a goal of prehospital infusion of 2 L of cold fluids
• Targeted temperatures– Higher temperatures might be preferred in patients for
whom lower temperatures convey some risk (bleeding)
– Lower temperatures might be preferred when patients have clinical features that are worsened at higher temperatures (seizures, cerebral edema)
Kim F, Nichol G, Maynard C, Hallstrom A, Kudenchuk PJ, Rea T, Copass MK, Carlbom D, Deem S, Longstreth WT Jr, Olsufka M, Cobb LA. Effect of prehospital
induction of mild hypothermia on survival and neurological status among adults with cardiac arrest: a randomized clinical trial. JAMA. 2014;311:45–52
Callaway et al. Part 8: Post–Cardiac Arrest Care 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care. Circulation. 2015;132(suppl 2):S465–S482
Naloxone
• 2015: “For patients with known or suspected
opioid addiction who are unresponsive with
no normal breathing but a pulse, it is
reasonable for appropriately trained lay
rescuers and BLS providers…to administer
intramuscular (IM) or intranasal (IN)
naloxone”
Kleinman ME, et al. Part 5: Adult Basic Life Support and Cardiopulmonary Resuscitation Quality 2015 American Heart Association Guidelines
Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132[suppl 2]:S414–S435
NaloxoneNaloxoneNaloxoneNaloxone
• Available in IV, IM, SQ, IN, Nebulizer
• Most common forms in BLS or out of hospital situations
• Intranasal: initial dose 2mg repeated every 3 to 5 minutes as needed
• Auto-injector (single dose): 0.4mg IM repeated every 3 to 5 minutes as needed
Lavonas EJ, Drennen IR, Gabrielli A, et al. Part 10 Special Circumstances of Resuscitation 2015 American Heart
Associateion Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
Circulation. 2015;132[suppl 2]:S501-S518.
Summary
• Compression Rate: 100-120 compressions/min
• Compression Depth: 2in-2.4in
• Vasopressin removed from algorithm
• Lidocaine?
• Targeted temperature management 32°C-36°C
• Naloxone addition
Other Updates
• BLS/CPR– Check for pulse and look for normal respirations at the
same time• 5-10 seconds maximum
– Ventilation rate with advanced airway• 1 breath every 6secs; no pausing of compressions
– Full chest recoil between chest compressions
– Manual compressions remain standard• Mechanical chest compression devices no demonstrated benefit
• ACLS– No routine use of O2 in ACS with normal O2 Saturation
(SPO2<94%)
Kleinman ME, et al. Part 5: Adult Basic Life Support and Cardiopulmonary Resuscitation Quality 2015 American Heart Association Guidelines
Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132[suppl 2]:S414–S435
Source: Grandview Team Pharmacy
DOPAMINE SODIUM
BICARB
DEXTROSE
NORMAL SALINE
Source: Grandview Team Pharmacy
EPINEPHRINE ATROPINE
LIDOCAINE
NALOXONE
NOREPINEPHRINE CALCIUM
CHLORIDE
MAGNESIUM
DIPHENHYDRAMINE
AMIODARONE
ADENOSINE
Interactive with ACLS!
Reviewing the Basics and a 2015
Update
Dan Israel, PharmD
Nick Wolters, PharmD
April 22, 2016
Grandview Medical Center: Dayton, OH