2015 AHA BLS And

Update 2015 AHA BLS and

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By Karen Jean Craig-Brangan, BS, RN, EMT-P, and Mary Patricia Day, MSN, RN, CRNA

ADVANCED CARDIOVASCULAR life support (ACLS) encompasses the entire spectrum of care from basic life support (BLS) to postcardiac arrest care. The 2015 American Heart Association (AHA) guidelines include recommendations on the use of I.V./intraosseous (I.O.) epinephrine, I.V./I.O. vasopressin during cardiac arrest, and

end-tidal carbon dioxide (ETCO2) measurements to predict patient outcome.1 Let’s take a closer look at these changes and more.

Managing cardiac arrest in an adult The Adult Cardiac Arrest Algorithm outlines a plan of care for the patient in cardiac arrest sec- ondary to pulseless ventricular tachycardia (pVT)/ ventricular fibrillation (VF). After determining unresponsiveness, apnea, and pulselessness, the clinician administers chest compressions and ventilations at a ratio of 30:2 respectively until an advanced airway is in place. Advanced air- ways include an endotracheal tube (ETT) or supraglottic airway (SGA) device such as a laryngeal mask airway, laryngeal tube, or esophageal obturator airway. The new BLS guidelines recommend a compression rate of at least 100/minute and no greater than 120/minute, and a compression depth of at least 2 in (5 cm) and no greater than 2.4 in (6 cm) for an average adult.2 Upper limits for both compression rate and depth have been provided

TOCK in the updated guidelines based on preliminary /iS data suggesting that excessive compression MAGES I rates and depths can adversely affect patient outcomes. Push hard and fast, rotating the compres- USINESS B sor role every 2 minutes to prevent fatigue. Avoid ONKEY

M excessive positive pressure ventilations, which

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Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. can increase intrathoracic pressure the cardiac arrest. The choice of an and reduce cardiac output, and advanced airway depends on the provide oxygen when available at skill level and training of the clini- maximum concentration by bag- cian placing it. No high-quality valve mask or advanced airway to evidence supports favoring endo- maximize the oxygen content of arte- tracheal intubation over bag-mask rial blood.2 ventilation or another advanced Attach the monitor/defibrillator as airway device in relation to overall soon as it’s available and analyze the survival or a good neurologic cardiac rhythm. Treat pVT/VF outcome.1 with defibrillation. Based on their Continuous waveform capnogra- greater success in dysrhythmia termi- phy for ETCO2 measurements nation, defibrillators using biphasic remains the most reliable method waveforms (biphasic truncated expo- of confirming and monitoring ETT nential or rectilinear biphasic) are placement when used in addition preferred to monophasic defibrilla- to clinical assessment. If continu- tors. The recommended energy dose ous waveform capnography isn’t for biphasic defibrillators is 120 to available, clinicians may use a

200 joules (J); if the manufacturer’s colorimetric and nonwaveform CO2 recommended energy dose is un- detector, an esophageal detector known, using the maximum energy device, or an ultrasound transducer dose available should be considered. Avoid excessive positive placed transversely on the anterior Subsequent defibrillation energy neck above the suprasternal notch doses should be equivalent or higher. pressure ventilations, to identify endotracheal or esopha- The shock energy dose for a mono- which can increase geal intubation.1 phasic defibrillator is 360 J. Perform intrathoracic pressure After an advanced airway is CPR for 2 minutes after defibrillation and reduce cardiac properly placed, the patient should and obtain I.V. or I.O. access if not be ventilated at a rate of 1 breath already established. output. every 6 seconds (10 breaths/ If VF/pVT persists with a rhythm minute) while continuous chest check during the compressor role dose epinephrine was no more ben- compressions are being performed. change at 2 minutes, defibrillate eficial than standard-dose epineph- This is a change from the previ- again. Biphasic doses can be equiv- rine in terms of survival to discharge ously recommended 1 breath every alent to the first shock administered with good neurologic recovery, sur- 6 to 8 seconds (8 to 10 breaths/ (120 to 200 J) or higher. Monopha- vival to discharge, or survival to minute), again to simplify the sic doses remain at 360 J. If the hospital admission. algorithm for learners. defibrillator unit is capable of esca- A single dose of I.V./I.O. vaso- Continuous waveform capnogra- lating energies, it’s reasonable to use pressin was an option to consider in phy can be used to evaluate the them for the second and third pVT/VF, pulseless electrical activity quality of CPR; for instance, an 1 shock. (PEA), and asystole to replace either ETCO2 less than 10 mm Hg or an After the second defibrillation the first or second dose of I.V./I.O. arterial relaxation diastolic pressure attempt, continue CPR for 2 min- epinephrine in the 2010 guidelines. less than 20 mm Hg indicates a utes and administer I.V./I.O. epi- However, one notable change in the need to improve CPR quality by nephrine 1 mg. This dose may be 2015 guidelines is the removal of optimizing chest compression repeated every 3 to 5 minutes. Epi- vasopressin from the adult cardiac parameters. For example, assess nephrine’s vasoconstrictor effects, arrest algorithm. Studies indicate compression rate, depth, and which increase coronary and cere- that vasopressin has no advantage chest recoil. bral perfusion pressure during CPR, over epinephrine and has been re- If pVT/VF persists, another shock are beneficial in cardiac arrest. How- moved to simplify the cardiac arrest is administered after 2 minutes of ever, current research doesn’t sup- algorithm.1 CPR. At this time, an antiarrhythmic port the routine use of high-dose The team leader may consider agent may be considered. Recom- I.V./I.O. epinephrine (range of 0.1 to placing an advanced airway and mendations include I.V./I.O. amio-

0.2 mg/kg). In clinical trials, high- using ETCO2 measurements during darone; I.V./I.O. lidocaine may be

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Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. considered as an alternative to amio- the need for targeted temperature darone for pVT/VF unresponsive to management (TTM) and interven- Reversible causes CPR, defibrillation, and vasopressor tions for ST-elevation myocardial of cardiac arrest therapy. infarction (STEMI). in an adult1 The patient should be evaluated Avoiding hypoxemia that can for an underlying reversible cause worsen organ injury is a top prior- Assess adults with persistent dysrhythmias for the following of the persistent dysrhythmia using ity. Administer the highest available potentially reversible “Hs and Ts” the “Hs and Ts” as recommended oxygen concentration until the and initiate appropriate 3 in the 2010 AHA guidelines. (See arterial oxyhemoglobin saturation interventions. Reversible causes of cardiac arrest in or the partial pressure of arterial • hypovolemia • an adult.) oxygen (PaO2) can be measured. hypoxia • Once return of spontaneous cir- At that point, decrease the FiO2 to hydrogen ion (acidosis) culation (ROSC) from cardiac arrest maintain a saturation of 94% to • hypo-/hyperkalemia due to pVT/VF is achieved, the 99%. Remember, peripheral • hypothermia 2015 guidelines state that evidence vasoconstriction may make using • tension pneumothorax • is inadequate to support routine pulse oximetry difficult immedi- tamponade, cardiac • use of lidocaine or beta-blockers. ately after ROSC. toxins • thrombosis, pulmonary In addition, no data support the Recommended ventilation goals • thrombosis, coronary. routine use of steroids alone for include the maintenance of normo-

patients experiencing in-hospital carbia (ETCO2, 30 to 40 mm Hg or 1 cardiac arrest. PaCO2, 35 to 45 mm Hg). Modify least 24 hours. Outcome prediction these goals as needed based on such for patients not treated with TTM Asystole/PEA factors as acute lung injury, high air- should occur no earlier than 72 The adult cardiac arrest algorithm way pressures, or cerebral edema.4 hours after cardiac arrest. Patients also outlines a plan of care for the Keep in mind that if the patient’s treated with TTM are typically eval- patient presenting with asystole or temperature is below normal, PaCO2 uated at 4.5 to 5 days after ROSC. PEA. This involves high-quality CPR lab values may be higher than the The 2015 guidelines recom- as previously described. patient’s actual values. mend against the routine initiation After I.V./I.O. access is estab- Managing BP is particularly of induced cooling in the prehos- lished, epinephrine 1 mg is recom- important. Studies demonstrate a pital setting. After rewarming from mended every 3 to 5 minutes. The significant relationship between TTM to normothermia, fever, use of vasopressin as an alternative systolic BP and mean arterial pres- which is associated with worsen- to epinephrine has been removed sure (MAP) and patient outcomes. ing ischemic brain injury, should from the asystole/PEA algorithm in Immediately correct hypotension, be prevented. the 2015 guidelines.1 An advanced defined as a systolic pressure of less The 2015 postcardiac arrest airway (ETT or SGA device) with than 90 mm Hg or MAP less than guidelines also address seizure continuous waveform capnography 65 mm Hg.4 detection and treatment. Electroen- should be considered as the resusci- The 2010 guidelines encouraged cephalography (EEG) should be tative effort continues. The patient is consideration of induced hypother- promptly performed and interpret- reevaluated every 2 minutes for the mia (32 to 34° C [89.6 to 93.2° F] ed in comatose patients after ROSC presence of a shockable rhythm. Re- for 12 to 24 hours) for most coma- and monitored frequently or con- versible causes should be considered tose patients after cardiac arrest to tinuously to diagnose seizure activ- using the Hs and Ts. improve neurologic outcomes. The ity.4 The guidelines recommend term targeted temperature manage- treating status epilepticus in ROSC Postcardiac arrest care ment (TTM) is now used to refer to with the same antiepileptic drug

In ROSC, ETCO2 increases abruptly the range of temperature targets rec- therapy used for status epilepticus (typically to 40 mm Hg or more) ommended in the postresuscitation caused by other etiologies. and a spontaneous arterial pressure period. TTM is recommended for Acute coronary syndromes (ACS) waveform is present with intra- comatose adult patients with ROSC are often a cause of cardiac arrest. arterial monitoring.1 After ROSC, after cardiac arrest. TTM involves A 12-lead ECG obtained early after patient-care goals include optimiz- selecting a temperature between 32 ROSC will identify patients with ing ventilation and oxygenation, and 36° C (89.6 and 96.8° F) and ST-segment elevation and facilitate treating hypotension, and evaluating maintaining that temperature for at rapid coronary angiography and www.Nursing2016.com February l Nursing2016 l 43

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. intervention. Emergent coronary encourage the patient with chest angiography and intervention can pain to chew and swallow 1 adult be performed whether the patient is 325-mg aspirin or 2 to 4 low-dose conscious or comatose.4 “baby” aspirin (81 mg each) if the patient has no history of aspirin Termination of efforts allergy or other contraindications As the 2015 guidelines recom- to aspirin use.6 mend, ETCO2 readings obtained by continuous waveform capnog- Recommendations for raphy can be used as a component pregnant patients to guide the decision to terminate Priorities in the resuscitation of resuscitative efforts in the intu- the pregnant patient include high- bated patient. Failure to achieve an quality CPR and the relief of aorto-

ETCO2 of greater than 10 mm Hg caval compression with manual left after 20 minutes of CPR may be lateral uterine displacement (LUD) used as a component to decide to during chest compressions if the terminate care. However, it’s im- fundus height is at or above the portant not to use ETCO2 mea- level of the umbilicus. In cases of surements in isolation. ETCO2 nonsurvivable maternal trauma or measurements can’t be used in pa- prolonged pulselessness, delivery tients who aren’t intubated because by cesarean section should be con- studies included only intubated sidered if the fundus height is at patients.1 The 2015 guidelines or above the umbilicus and ROSC The 2010 recommendations for recommend against hasn’t been achieved with adequate treatment of patients with stable the routine initiation of resuscitative efforts. Typically, C- and unstable bradycardia or tachy- induced cooling in the section delivery should be consid- cardia with a pulse remain un- ered 4 minutes after cardiac arrest changed. The 2015 AHA guidelines prehospital setting. or resuscitative efforts and manual do, however, address the care of LUD. When resuscitation efforts are patients with stroke or ACS, and 12-lead ECG as early as possible deemed futile (as in nonsurvival pregnant patients. in patients with suspected ACS maternal trauma or prolonged with interpretation by an appropri- pulselessness), there is no reason Recommendations for stroke ately trained healthcare provider to delay cesarean delivery. With a Because stroke is a leading cause of in conjunction with computer- witnessed arrest, cesarean delivery death and disability in the United assisted ECG interpretation. This should be considered 4 minutes States, the 2015 AHA guidelines 12-lead ECG will facilitate the ear- after the start of resuscitative mea- have placed an increased emphasis ly diagnosis and treatment of pa- sures or onset of cardiac arrest.7 on stroke symptom recognition tients with STEMI, reducing time for faster diagnosis and treatment. to first medical contact as well as Current and future changes The Face, Arm, Speech, Time door-to-needle (fibrinolysis) and In summary, the 2015 AHA guide- (FAST) and Cincinnati Prehospital door-to-balloon (percutaneous lines for ACLS contain some new Stroke Scale (CPSS), two stroke coronary intervention) time when recommendations, such as the re- assessment systems, are now rec- appropriate. moval of vasopressin from the Adult ommended for use by first aid The 2015 guidelines also address Cardiac Arrest Algorithm and a providers.5 early aspirin administration by first change in the ventilation rate for the aid providers to patients with chest intubated patient during CPR to a Recommendations for ACS pain due to probable myocardial simplified 10 breaths/min (1 every 6 The 2015 AHA guidelines for ACS infarction. Research indicates seconds), and a temperature range of can be utilized by all providers that early aspirin administration 32 to 36° C for 24 hours when using involved in the care of the patient, significantly reduces mortality. It’s TTM after ROSC. from initial medical contact until recommended that while waiting What does the future hold? transfer from the ED. These guide- for the arrival of emergency medi- History tells us we can expect the lines stress the need for a prehospital cal services, first aid providers may integration of new approaches to

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Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. resuscitative efforts. Research also Cardiopulmonary Resuscitation Quality: 2015 Cardiopulmonary Resuscitation and Emergency American Heart Association Guidelines Update for Cardiovascular Care. Circulation. 2015;132(18 suggests that our educational ap- Cardiopulmonary Resuscitation and Emergency suppl 2):S483-S500. proach to teaching BLS and ACLS Cardiovascular Care. Circulation. 2015;132(18 7. Lavonas EJ, Drennan IR, Gabrielli A, et al. Part suppl 2):S414-S435. may change in structure. For in- 10: Special Circumstances of Resuscitation: 2015 3. Neumar RW, Otto CW, Link MS, et al. Part 8: American Heart Association Guidelines Update for stance, shorter, more frequent edu- Adult Advanced Cardiovascular Life Support: Cardiopulmonary Resuscitation and Emergency cational sessions, such as roving 2010 American Heart Association Guidelines for Cardiovascular Care. Circulation. 2015;132(18 Cardiopulmonary Resuscitation and Emergency suppl 2):S501-S518. BLS scenarios or ACLS mock codes, Cardiovascular Care. Circulation. 2010;122(18 may be more efficient and cost- suppl 3):S729-S767. 4. Callaway CW, Donnino MW, Fink EL, et al. effective strategies for keeping key Part 8: Post-Cardiac Arrest Care: 2015 American Karen Jean Craig-Brangan is owner/president and concepts fresh in our minds. ■ Heart Association Guidelines Update for CEO of EMS Educational Services, Inc., in Chelten- Cardiopulmonary Resuscitation and Emergency ham, Pa., and AHA training center manager, Temple University Health System, Philadelphia, Pa. Mary Cardiovascular Care. Circulation. 2015;132(18 Patricia Day is a certified registered nurse anesthetist REFERENCES suppl 2):S465-S482. at Temple University Hospital in Philadelphia, Pa. 1. Link MS, Berkow LC, Kudenchuk PJ, et al. Part 5. Singletary EM, Charlton NP, Epstein JL, 7: Adult Advanced Cardiovascular Life Support: et al. Part 15: First Aid: 2015 American Heart 2015 American Heart Association Guidelines Association and American Red Cross Guidelines The authors and planners have disclosed no potential Update for Cardiopulmonary Resuscitation and Update for First Aid. Circulation. 2015;132(18 conflicts of interest, financial or otherwise. Emergency Cardiovascular Care. Circulation. suppl 2):S574-S589. 2015;132(18 suppl 2):S444-S464. 6. O’Connor RE, Al Ali AS, Brady WJ, et al. Part 2. Kleinman ME, Brennan EE, Goldberger 9: Acute Coronary Syndromes: 2015 American ZD, et al. Part 5: Adult Basic Life Support and Heart Association Guidelines Update for DOI-10.1097/01.NURSE.0000476229.95631.bf