REBEL Cast Ep77: 2019 ACLS Update

The American Heart Association (AHA) released a focused update in 2019, for advanced cardiovascular life support (ACLS) guidelines, to addend those published in 2017 and 2018 for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care.  These recommendations were based on evidence identified by the 2019 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR) from the International Liaison Committee on Resuscitation (ILCOR). 

This ACLS Update addresses three main concerns:

1. Advanced Airway management
2. Vasopressors in cardiac arrest
3. Extracorporeal CPR (ECPR) during cardiac arrest

REBEL  Cast Episode 77 – 2019 ACLS Update

Advance Airway Management

• Recommendation #1:
  1. Either BMV or an advanced airway strategy may be considered during CPR for adult cardiac arrest in any setting (Class 2b; Level of Evidence B-R).
  2. If an advanced airway is used, the SGA can be used for adults with OHCA in settings with low tracheal intubation success rate or minimal training opportunities for ETT placement (Class 2a; Level of Evidence B-R).
  3. If an advanced airway is used, either the SGA or ETT can be used for adults with OHCA in settings with high tracheal intubation success rates or optimal training opportunities for ETT placement (Class 2a; Level of Evidence B-R).
  4. If an advanced airway is used in the in-hospital setting by expert providers trained in these procedures, either the SGA or ETT can be used (Class 2a; Level of Evidence B-R).
  5. Frequent experience or frequent retraining is recommended for providers who perform ETI (Class 1; Level of Evidence B-NR).
  6. Emergency medical services systems that perform prehospital intubation should provide a program of ongoing quality improvement to minimize complications and to track overall SGA and ETT placement success rates (Class 1; Level of Evidence C-EO). 
• Bag Valve Mask (BMV): allows for initial ventilation in patients during resuscitation from cardiac arrest but does not protect against aspiration of gastric secretions. As a result, advanced airway devices are frequently placed by providers during CPR 
• Placement of advanced airway equipment however can be difficult especially during CPR particularly without holding compressions, thus risks of withholding CPR versus obtaining definitive airway immediately need to be weighed based on clinical setting.
• ILCOR performed a systematic review evaluating the effects on overall cardiac arrest survival and neurological outcome when providers used an advanced airway (ie. Endotracheal tube (ETT) or Supra-glottic airway (SGA)) compared with BMV for both out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA)). 
• REBEL Thoughts: The recommendations are fairly loose and accommodating depending on multiple scenarios. The recommendations literally state “the ultimate decision on both the type and timing of an advanced airway will require consideration of a host of patient and provider characteristics that are not easily defined in a global recommendation”.  So the decision of which airway management technique used will be a multi-factorial decision depending on: location (out-of-hospital or in-hospital), transport time, equipment available, as well as level of expertise of provider. Weighing risks and benefits of aspiration vs. definitive airway. Start with a BVM/SGA, then place advanced airway when you can, monitor airway with EtCO2 capnography. 

Vasopressors

• Recommendation #2: We recommend that epinephrine be administered to patients in cardiac arrest (Class 1; Level of Evidence B-R). On the basis of the protocol used in clinical trials, it is reasonable to administer 1 mg every 3 to 5 minutes (Class 2a; Level of Evidence C-LD). 
  • Epinephrine has both alpha-adrengeric (vasoconstriction) effects which improve cerebral and coronary perfusion pressure during CPR, but also has beta-adrenergic effects (negatively may increase myocardial O2 demand  & may be pro-arrythmic)
  • Regardless the 2010 ACLS and 2015 AHA guidelines had recommended epinephrine (1mg IV/IO q 3-5 mins) during adult CPR. 
  • Two large RCT’s reviewed in 2019 compared epinephrine 1mg q3-5 mins x 10 doses vs. placebo, pooled analysis showed the use of epinephrine for patients with any initial rhythm significantly increased patient survival to hospital discharge. 
  • However the larger PARAMEDIC 2 trial looked at survival BEYOND hospital discharge, at 30 days. PARAMEDIC-2 Trial showed favorable increase survival with favorable neurologic outcomes at 3 mos for non-shockable rhythms treated with epinephrine compared to shockable ones. (note: this study did not investigate long term survival with favorable outcome, only at 3 mos)
  • PARAMEDIC-2 also showed us that there may be a difference in epinephrine effect on favorable neurological outcomes based on the type of arrest rhythm.
    • Non-shockable rhythm treated w epinephrine → increased survival with favorable neurologic outcome at 3 mos (approached statistical significance). 
    • Shockable rhythm treated with epinephrine → showed no difference in survival with favorable neurologic outcome at 3 mos 
  • REBEL Thoughts: Unfortunately we don’t know the appropriate dose of epinephrine in OHCA…there is no better research at a high enough level of evidence to change this recommendation. 

High Dose Epinephrine

• Recommendation #3: High-dose epinephrine is not recommended for routine use in cardiac arrest (Class 3: No Benefit; Level of Evidence B-R).
  • High-dose epinephrine (0.1-0.2 mg/kg) in theory was presumed to correlate to increased coronary perfusion…however there are downsides in the post-arrest period. 
  • ILCOR reviewed a number of studies that compared standard epinephrine to high-dose epinephrine, none of which demonstrated benefit in discharge with favorable neurologic outcome; survival to discharge, or survival to hospitalization. Therefore it is not recommended in cardiac arrest. 
  • REBEL Thoughts: Nothing to add here.  High dose epi should simply not be used as it has been shown to increase poor outcomes in OHCA

Vasopressin vs. Epinephrine

• Recommendation #4: Vasopressin may be considered in a cardiac arrest but offers no advantage as a substitute for epinephrine in cardiac arrest (Class 2b; Level of Evidence C-LD). 
• Recommendation #5: Vasopressin in combination with epinephrine may be considered during cardiac arrest but offers no advantage as a substitute for epinephrine alone (class 2b)
• Recommendation #6A: With respect to timing of epinephrine administration during cardiac arrest in a non-shockable rhythm, it is reasonable to give epinephrine as soon as possible
• Recommendation #6B: With respect to epinephrine for shockable rhythms, it is reasonable to give epinephrine after initial defibrillation has failed. 
  • Vasopressin was initially removed from the ACLS algorithm in 2015 after trials demonstrated no significant benefit compared with or in addition to epinephrine. 
  • Despite this continued lack of evidence it seems the new guidelines now state you can use it, but should not be substituted for epinephrine.
• REBEL Thoughts: Vasopressin has not demonstrated superiority to epinephrine in cardiac arrest.  Despite this continued lack of evidence it seems the new guidelines now state you can use it, but should not be substituted for epinephrine. The consensus was that use of epinephrine alone as a vasopressor during cardiac arrest keeps things SIMPLE in the arrest treatment algorithm.

Extracorporeal CPR (ECPR/ECMO)

• RECOMMENDATION 7#: There is insufficient evidence to recommend the routine use of ECPR for patients with cardiac arrest. It may be considered for select patients as a rescue therapy when conventional CPR is failing in settings in which it can be expeditiously implemented (ie: ECMO on sight)
  • Few observational studies 
  • No RCT’s on ECPR for OHCA or IHCA
  • Majority of studies showed improved neurologic outcomes associated with ECPR however evidence thus far is insufficient (single center studies, no RCT, varying inclusion criteria and settings)
• REBEL Thoughts: If you have ECMO capacity at your center, initiating ECMO protocol for select patients appears beneficial enough and warranted. Selection criteria is key here, including witnessed arrest, younger patients, few co-morbidities, salvageable underlying cause of arrest etc. 

Clinical Bottom Line:

1. AIRWAY: OHCA-airway SGA is simpler to do but no better than intubation. In the ED definitive airway is important for prevention of aspiration and secure airway, however do not let this interrupt CPR
2. VASOPRESSORS: Epinephrine…for now remains 1mg q3 – 5 minutes; just say NO to high-dose epinephrine; and vasopressin is back?! 
3. ECMO:  Reasonable at institutions that have it available, but patient selection will be key. 

Co-Host

References:

1. Panchal A, Berg K, et al. AHA Focused Update. 2019 American Heart Association Focused Update on Advanced Cardiovascular Life Support: Use of Advanced Airways, Vasopressors, and Extracorporeal Cardiopulmonary Resuscitation During Cardiac Arrest. Circulation. 2019; 140:00-00. PMID:31722552 
2. Jacobs IG, Finn JC, et al. Effect of adrenaline on survival in out-of-hospital cardiac arrest: a randomised double- blind placebo-controlled trial. Resuscitation. 2011;82:1138–1143. PMID: 21745533 
3. Perkins G, Ji C et al. PARAMEDIC2 Collaborators. A randomized trial of epinephrine in out-of-hospital cardiac arrest. N Engl J Med. 2018;379:711–721.  PMID: 30021076
4. Perkins GD, Kenna C, et al. The effects of adrenaline in out of hospital cardiac arrest with shockable and non-shockable rhythms: findings from the PACA and PARAMEDIC-2 randomised controlled trials. Resuscitation. 2019;140:55–63. PMID: 31116964

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)

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