USA Goes Beyond ACLS

1. b-card symposium
Cardiac Arrest in the Field Today
U A Goes Beyond ACLS
Tuesday
March 7th
2017
Nicolas PESCHANSKI, MD, PhD

2. Acknowledgments
Salim R. Rezaie, MD
@srrezaie
Tom R. Bouthillet, EMT
@tbouthillet

3. Cardiac Arrest in the Field
USA

4. 2016
S
T
A
T
E
of
the
U
N
I
O
N

5. Principles for EMS in the Field
Immediate Recognition & EMS Activation (911)
Early CPR w/ Emphasis on Chest Compressions
Rapid Defib’
Effective ACLS
Integrated Post-Resus Care

6. Cardiac Arrest Process of Care
Call Processing
Collapse
(Time Zero)
Reaction
Time
Pit Crew / High Performance CPR
Public Access Defibrillation
(Social Media Citizen Responders)
9-1-1
Call
Dispatch
En Route
(Wheels-Up)
At Patient
(CPR)
First Shock
Arrival
Curbside
(Wheels Down)
Second Shock
Third Shock
Fourth Shock
Sweet Spot
Telephone CPR (T-CPR)
Dispatcher Instructions
ROSC

7. “It isn’t complicated
but it’s not easy.”

8. Multidisciplinary
Approach

9. Is the patient conscious?
Isthepatientbreathingnormally?
Begin CPR instructions!
No!
No!
9-1-1
DISPATCH

10. ON
SCENE
BLS
3% to 78%
Al-Khatib SM et al. Circulation CVQO 2016

11. ON
SCENE
BLS+
T-CPR & More

12. Good Sam
Apps
ON
SCENE
BLS+

13. EMS
Teams
ACLS
Fire Dept
Stations

14. CPR
Epi
Pulse
EMS
FOCUS

15. C
P
R
EMS
ACLS

16. 2015 AHA
CPR
RATE
100 – 120/min
DEPTH:
2in - 2.4in
RECOIL
Allow Full Recoil
INTERRUPTIONS
Minimize Pauses
RULES
Guideline
Update

17. CPR: Man or Machine?
vs
EMS
ACLS+
Gates S et al. Resuscitation 2015

18. Cunningham LM et al. AJEM 2012
PAUSE = Decreased Perfusion
P
E
R
F
U
S
I
O
N
P
R
E
S
S
U
R
E
TIME
No Pause… Should Be Your Cause!

19. EMS
ACLS*
0%
10%
20%
30%
40%
50%
60%
Survival to Discharge
HQ-CPR
Davis DP et al. Resuscitation 2015

20. RhythmEMS
ACLS
vs
Shockable Non-Shockable

21. Early DefibrillationEMS
ACLS

22. Pulse
Checks
EMS
ACLS

23. >5sec 43%
>10sec 4%
Ochoa FJ et al. Resuscitation 1998
Pulse Check
EMS
ACLS
Problem with Manual

24. Is the Pulse Check Dead?EMS
ACLS

25. Trans Thoracic Echo
No Cardiac
Activity on
TTE
ROSC = 2.4%
Cardiac
Activity on
TTE
ROSC = 51.6%
Blyth L et al. Acad Emerg Med 2012
EMS
ACLS+

26. Pseudo-PEA vs PEAEMS
ACLS+

27. EMS
ACLS

28. IV Epinephrine
1mg q3 – 5min
MAYBE
Reasonable
Class I (Strong)
Benefit>>>Risk
Class IIa (Moderate)
Benefit>>Risk
Class IIb (Weak)
Benefit≥Risk
Class III (No Benefit)
Benefit=Risk
Class III (Harm)
Risk>Benefit
1mg q3 – 5min
MAYBE
Reasonable
EMS
ACLS

29. Evidence
for Epi
OHCA
EMS
ACLS+
ROSC ≠
Neuro
Intact Survival
↑ ROSC
No ↑ Survival
↑ Mortality

30. IV Access
in the Field
EMS
ACLS

31. IO vs PIV
Higher
Success Rate
Faster Access
Achieved
EMS
ACLS+

32. Cardiac Arrest Ventilation
Fouche PF et al. Prehosp Emerg Care 2014
> >

33. BVM
Vent is
Difficult!
EMS
ACLS
Guyette FX et al. Prehosp Emerg Care 2007

34. EMS
ACLS+
Is There Still Room for ETI?
Sunde GA et al. Scan J Trauma Resus Emerg Med 2015

35. EMS
ACLS+
Maybe… YES
Benoit JL et al. Resuscitation 2015

36. b-card
ACLS & Beyond…?ACLS
2020

37. b-card symposium
Thank You for Your Attention
Q & A
Tuesday
March 7th
2017
Nicolas PESCHANSKI, MD, PhD