2015 ALS Guidelines update. Is there something new (and good)? What really changes in our daily practice.

Who read the pervious post, Evidence Based Medicine. Beyond the dogma, can understand how my attention is focused on applicability of EBM based guidelines in my clinical context, so I want to underline some controversy of these guidelines, and at the same time, to introduce which are the most relevant statements for my clinical practice and for the way we want to evolve our local prehospital emergency system.

First of all the things you already heard almost everywhere over the blogsphere.

Minor, and not so relevant, changes. Minor influence on clinical practice. Just a reinforcement to key messages issued on the previous version of the guidelines. 

Let’s get deep into the guidelines :

The quality of chest compressions is now well specified. Push at least 5 cm but no more than 6 cm. Rate at least 100, maximum 120 per minute. So to assess quality of compressions (and of the whole CPR) you need a metronome and a commercial feedback device (acoustic or visive) to calculate compressions rate and deepness. I suggest capnography as alternative method to monitor chest compression quality.

Attribution:First 10EM.

Great emphasis is given to minimising interruption of chest compressions. So why not to introduce the hands only CPR at least at the beginning of resuscitation? There are good evidence for good neurological outcomes with this technique (associated to unsynchronised ventilation) and these guidelines lost the chance to make a real change on the way to a better patient centred care. 

Epinephrine at 1 mg dose every 3-5 minutes is still on board despite no evidence on improving outcome (and some signal toward the detrimental side of the story). For sure such a massive dose of vasoactive drug in a patient with low flow state and low metabolic activity, when circulation restart is a big issue for the heart and the brain. Pramedic 2 trial is ongoing and will give us more definitive answers. 

Attribution: The Resuscitationist. Sharing some raw data and thoughts on the LUCAS, ITD, CPR and Epi from my lab December 5, 2015 by Jason Bowman

PEA and asystole are still considered similar entity and have a common algorithm. This is wrong, and we already treated this topic (Forget ACLS guidelines if you are dealing with Pulseless Electric Activity. Part 1. Forget ALS Guidelines when dealing with PEA. Part 2.). 2015 Guidelines reiterated this controversy. 

Capnography is reinforced as a useful companion to guide resuscitation along all its duration, but just a shy recommendation was released about is use as tool to guide the termination of resuscitation efforts. Guidelines stated that a value of less than 10 mmHg after 20 min is strongly predictive of bad outcome but “End-tidal CO2 values should be considered only as part of a multi-modal approach to decision-making for prognostication during CPR.”But why not mentioning the combination of US (not beating heart) and low EtCO2(<10mmHg), that gives specificity and sensitivity (I just found 1 case report who mentioned ROSC in such a situation) to the prediction rule and is commonly use as parameter for termination of resuscitation? 

Those, from my point of view, the most controversial point of the guidelines.  

Let’s talk now about the new and game changing points of this 2015 ALS Guidelines. They are not new to the majority of FOAMED world inhabitants. But now those statements can be spread to the vast population of emergency medicine professionals. 

POCUS is now integral part of the ALS algorithm. It is the gold standard for the determination of reversible causes of PEA. So why don’t make a step forward and differentiate PEA and pseudo-PEA via ultrasonography!  

External Life Support is a recommended option for selected group of patients. Mechanical  devices for chest compressions are not the standard when comes to conventional CPR. They became unmissable in particular circumstances like when transporting patients toward the ECMO center for external life support or for prolonged resuscitation scenarios. 

Traumatic cardiac arrest is not the poorest twin of medical cardiac arrest anymore, but finally he as a specific algorithm. This is not a complete news (already many of prehospital emergency services have operative procedure in that sense) but is important that also the normally conservative AHA and ERC stated this different approach. What they say. In case of trauma and cardiac arrest, if you decided to start CPR, do not waste time to compress the chest but treat reversible causes. Use US to help the diagnose. Consider to stop resuscitation efforts if there is not contractile activity of the heart at the end of the protocol. As previously mentioned, the case of PEA associated with a rising in EtCO2 values, even in absence of a detectable central pulse, that indicates great chance of ROSC (despite a condition of profound shock) is not mentioned.

Read more about this topic at: Mind of Resuscitation in Traumatic Cardiac Arrest

But what we really changed in our practice?
From March 2015 Florence EMS published a best practice that anticipated new guidelines trends.
External life support is part of our daily practice, mechanical chest compressors have been adopted for that reason in our emergency vehicles and our personalized US algorithm to detect reversible causes of CA is being taught to many colleagues who attended the prehospital US course in those months.
Use of capnography was already a standard practice in case of CA but we don’t missed the chance to reinforce the message about its use as marker of good quality CPR, restoration of spontaneous circulation and predictive of bad outcome when combined with a non beating heart.

Follow MEDEST to know more about ELS local protocol (and hopefully some case reports) and how to use POCUS  during the scheduled conduction of a ALS scenario. 

Visit MEDEST ALS 2015 Guidelines page for full text, posters adn video links to AHA and ERC Guidelines