New ACLS Guidelines

1
New ACLS Guidelines

• LCDR Phil Colmenares MD MPH
• Emergency Medicine Department
• Portsmouth Naval Medical Center

2
Objectives

• New ACLS algorithms

• Highlight changes in drug therapy

• Review some of the evidence for the changes

3
Relation of Collapse-to-CPR andDefibrillation to
Survival
0.6 0.5 0.4 0.3 0.2 0.1 0
Collapse-to-CPR interval (min) 1 5 10 15
Probability of Survival
0 5 10
15 20
Collapse to Defibrillation Shock (min)
Valenzuela et al. Circulation 1997963308.
4
ACLS
5
ACLS

• Drugs/Algorithms

6
ACLS

• Drugs/Algorithms
• ACS

7
ACLS

• Drugs/Algorithms
• ACS
• Stroke

8
ACLS

• Drugs/Algorithms
• ACS
• Stroke
• Electrolyte Abnormalities

9
ACLS

• Drugs/Algorithms
• ACS
• Stroke
• Electrolyte Abnormalities
• Toxicology

10
ACLS

• Drugs/Algorithms
• ACS
• Stroke
• Electrolyte Abnormalities
• Toxicology
• Environmental

11
ACLS

• Drugs/Algorithms
• ACS
• Stroke
• Electrolyte Abnormalities
• Toxicology
• Environmental
• Asthma

12
ACLS

• Drugs/Algorithms
• ACS
• Stroke
• Electrolyte Abnormalities
• Toxicology
• Environmental
• Asthma
• Anaphylaxis

13
ACLS

• Drugs/Algorithms
• ACS
• Stroke
• Electrolyte Abnormalities
• Toxicology
• Environmental
• Asthma
• Anaphylaxis
• Trauma

14
ACLS

• Drugs/Algorithms
• ACS
• Stroke
• Electrolyte Abnormalities
• Toxicology
• Environmental
• Asthma
• Anaphylaxis
• Trauma
• Pregnancy

15
(No Transcript)
16
AHA ECC Milestones
2000
PAD
1992 JAMA
1985-86 JAMA
ILC
1966 NRC/NSF AHA
1979-80 JAMA
1973-74 JAMA
Chain of Survival
Currents in ECC
AED
PALS
1958 MTM
1960 CPR
ACLS
BCLS
17
Linking AHA Evidence-Based Guidelines to ACLS
Treatment Recommendations
EVIDENCE
QUALITY
RECOMMENDATION

• Level 1 large randomized clinical
  trials
• Level 2 smaller randomized
  clinical trials
• Level 3 prospective, controlled,
  nonrandomized cohort studies
• Level 4 historic, nonrandomized cohort
  
• or case-control studies
• Level 5 case series, no control group
• Level 6 animal or mechanical model
• Level 7 extrapolations from existing
• data theoretical analyses
• Level 8 rational conjecture (common
• sense) common practice

• Excellent
• Good
• Fair
• Poor

• Class I
• Class II
• - Class II a
• - Class II b
• Class III
• Indeterminate

18
AHA Class Recommendations
19
AHA Recommendations

• Class I

- definitely helpful, - excellent Level I
evidence

• Class IIa

- acceptable, probably helpful - good supportive
evidence

• Class IIb

- acceptable, possibly helpful - fair supportive
evidence

• Class III

- not indicated, may be harmful

• Class Indeterminate

- not recommended - insufficient data
20
Ventricular Fibrillation
OLD
VF/VT
Shock X 3
Epinephrine
Class IIa
Shock
Lidocaine Bretylium MgSO4 Procainamide High Dose
Epi
Class IIa
Class IIb
21
Ventricular Fibrillation
OLD
NEW
VF/VT
VF/VT
Primary ABCD
Shock X 3
Shock X 3
Secondary ABCD
Epinephrine
Vasopressin Class IIb or
Epinephrine Class Indeterminate
Class IIa
Shock
Shock
Lidocaine Bretylium MgSO4 Procainamide High Dose
Epi
Class IIa
Amiodarone MgSO4 Procainamide Lidocaine High
Dose Epi
Class IIb
Class IIb
Class Indeterminate
22
High-Dose Epinephrine

• Stiell, et al. NEJM 1992
• Human, RCT (n650)
• Survival and neuro outcomes not improved

• Callaham, et al. JAMA 1992
• Human, RCT (n816)
• Increased ROSC and higher admission rates
• Survival and neuro outcomes not improved

23
Standard-Dose Epinephrine (SDE) vs High-Dose
Epinephrine (HDE) for Out-of-Hospital Cardiac
Arrest
p0.02
20
SDE (N260) HDE (N286)
p0.01
18
15
of Patients
13
10
10
8
p0.37
5
1.7
1.2
0
ROSC in the Field
Admission
Survival to Discharge
Callaham, et al. JAMA, 1992 ROSC return
of spontaneous circulation.
24
High-Dose Epinephrine

• Stiell, et al. NEJM 1992
• Human, RCT (n650)
• Survival and neuro outcomes not improved

• Callaham, et al. JAMA 1992
• Human, RCT (n816)
• Increased ROSC and higher admission rates
• Survival and neuro outcomes not improved

• Behringer, et al. Ann Intern Med 1998
• Human, Retrospective cohort study (n178)
• Increasing epi dose associated with poorer
  outcomes

25
Vasopressin

• Linder, et al. Anesthesiology 1992
• Human, Descriptive Study (n34)
• Vasopressin hormone levels are greater in
  patients with ROSC vs those with no ROSC

• Linder, et al. Heart 1996
• Human, Descriptive Study (n60)
• Same result as above

26
Epinephrine vs Vasopressin

• Linder, et al. Circulation 1995
• Pigs, RCT (n28)
• Vasopressin results in higher coronary perfusion
  pressures

• Prengel, et al. Crit Care Med 1996
• Pigs, RCT (n16)
• Vasopressin provided higher SVR and higher MAPs
• Reversible cardiac depressant effect with
  vasopressin

• Wenzel, et al. J Am Coll Cardiol 2000
• Pigs, RCT (n17)
• Survival Epi 0/6 (0) vs Vasopressin 6/6 (100)
• Vasopressin group had full neurologic recovery
  w/o cerebral pathology

27
Epinephrine vs Vasopressin

• Linder, et al. Lancet 1997
• Human, RCT (n40)
• Survival to admission Epi (35) vs Vasopressin
  (70) p.06
• Survival to 24 hr Epi (20) vs
  Vasopressin (60) p.02
• Survival to discharge Epi (15) vs Vasopressin
  (40) p.16

28
Epinephrine vs Vasopressin for Out-of-Hospital
Cardiac Arrest
Epinephrine (N20) Vasopressin (N20)
70
P0.06
70
60
P0.02
60
50
of Patients
40
P0.16
40
30
35
20
20
10
15
0
ROSC
24 h Survival
Survival to Discharge
Linder, et al. Lancet 1997349535. ROSC
return of spontaneous circulation.
29
Ventricular Fibrillation
OLD
NEW
VF/VT
VF/VT
Primary ABCD
Shock X 3
Shock X 3
Secondary ABCD
Epinephrine
Vasopressin Class IIb or
Epinephrine Class Indeterminate
Class IIa
Shock
Shock
Lidocaine Bretylium MgSO4 Procainamide High Dose
Epi
Class IIa
Amiodarone MgSO4 Procainamide Lidocaine High
Dose Epi
Class IIb
Class IIb
Class Indeterminate
30
Organization of Evidencefor a Particular
Intervention
Author year (n)
2
Excellent
9
Good
Supporting
1. Knoop 73 (20) 2. Kelty 80
(2530) 3. Mueller 74 4. Jackson 84 5. Sisson
85 (40) 6. Weinstein 63 (100) 7. Guevarra 95
(20/529) 8. Barbaella 85 9. Kelley 74 (23)
Fair
1
7
4,8
Net Class Indeterminate
8
7
6
5
4
3
2
1
Fair
3
5
Good
Neutral/Opposing
6
Excellent
8
7
6
5
4
3
2
1
Level
31
Quality and Level of Evidence Analysis Magnesium
in VF/VT Cardiac Arrest
Author year (n)
Excellent
Good
Supporting
Fair
3, 5, 6 8
1
1. Cannon 87(41) (Low Mg) 2. Miller 95
(62) 3. Perticone 92 (22) 4. Thel 97
(156) 5. Tzivoni 84 (3) (torsade) 6. Tzivoni
88 (12) (torsade) 7. Tzivoni 88 (5)
(PMVT) 8. Other torsade studies
8
7
6
5
4
3
2
1
7
2
Fair
Good
Neutral/Opposing
Excellent
4
8
7
6
5
4
3
2
1
Level
32
Magnesium for In-hospital Cardiac Arrest
60
PNS
Magnesium (N76) Placebo (N80)
60
50
54
50
40
43
of Patients
30
20
21
21
10
0
ROSC
24 h Survival
Survival to Discharge
Thel et al. Lancet 19973501272. ROSC
return of spontaneous circulation.
33
Magnesium in VF/VT Cardiac Arrest
CON
PRO

• One excellent level 2
• One fair level 4
• One fair level 5

• Three fair level 5 ( Mg torsade)
• One fair level 7
• Current practice level 8

Net Class IIB (low Mg level)
Unclassified (routine use)
34
Quality and Level of Evidence Analysis
Procainamide in VF/VT Cardiac Arrest
Author year (n)
Excellent
Good
Supporting
1. Giardina 73 (20) 2. Greenspan
80 3. JawadKanber 74 (14) 4. Marchlinski
84 5. Oseran 85 6. Redding 63 7. Stiell 95
(20/529) 8. Wynn 85 9. Yoon 74
(23) 10. Other EP Lab Studies
Fair
2, 4 5, 8 10
1
7
8
7
6
5
4
3
2
1
6, 9
Fair
Good
3
Neutral/Opposing
Excellent
8
7
6
5
4
3
2
1
Level
35
Procainamide in VF/VTCardiac Arrest
CON
PRO

• One good level 7
• Two fair level 7

• One fair level 4
• One fair level 5
• Fair human level 7
• Current practice level 8

Net Unclassified (for persistent VT/VF)
Class IIB (for recurrent VT/VF)
36
Quality and Level of Evidence Analysis Lidocaine
in VF/VT Cardiac Arrest
1. Alexander 99 (43704) 2. Anastasiou 94
(16) 3. Babbs 79 4. Borer 76 5. Carden 56
(23) 6. Chow 86 7. Dorian 86 8. Echt
89 9. Harrison 63 (12) 10. Harrison 81
(116) 11. Haynes 81 (146) 12. Herlitz 97
(1360) 13. Kentsch 88 (20) 14. Kerber
86 15. Lazzara 73 16. Lazzara 78 17. Lie
74 18. Olson 84 (108) 19. Redding 68
(105) 20. Sadowski 99 (903) 21. Spear
72 22. Vachiery 90 (18) 23. VanWalraven 98
(773) 24. Weaver 90 (199) 25. Other MI
trials 26. MI Meta-analyses
Author year (n)
Excellent
Good
Supporting
Fair
5
12
4, 9, 15, 16, 17 21, 25
Current Practice
8
7
6
5
4
3
2
1
10
Fair
1, 20 26
23, 24
13, 18
Good
2, 3, 6 7, 8, 14 19, 22
Neutral/Opposing
Excellent
11
4
8
7
6
5
3
2
1
Level
37
Lidocaine in Shock-refractoryOut-of-Hospital VF
N116 400 J X 2 Refractory VF
N62 Standard Resuscitation Lidocaine 100 mg
N54 Standard Resuscitation
Age 64.3 y 62 y Men 42 (78) 50
(80) Response time 5.2 min 4.9 min
Defibrillations 4.3 5 IV epi 29 (54)
PNS 33 (53) IC epi 27 (50) 30
(48) CaCl 30 (56) 40 (65) Intubation 16
(30) 31 (50) Esoph airway 45 (83) 44
(71)
Harrison et al. Ann Emerg Med 198110420.
38
Lidocaine in Shock-refractoryOut-of-Hospital VF
Lidocaine No Lidocaine
50
46
45
PNS
40
30
24
of Patients
20
17
11
10
2
0
Survived to Discharge
Ongoing VF in ER
Admitted to Hospital
Outcome
Harrison et al. Ann Emerg Med 198110420.
39
Out-of-Hospital VF Cardiac Arrest
N20
Shock Lidocaine 100 mg Bicarb 1 mg/kg Shock X 2
Amiodarone 300 mg N10
Lidocaine 100 mg N10
Shocks
4.6 1.1
6.7 2.4
Plt0.05
Admitted alive to hospital
N8 (80)
Plt0.05
N2 (20)
Kentsch et al. Intensivm Medizin 19882570.
40
Effect of Lidocaine on Short-term Survival From
Cardiac Arrest
N773 patients with in-hospital cardiac arrest
50
40
30
Patients given Lidocaine
20
10
0
15
5
25
Time from Start of CPR (min)
Cox proportional hazards model (95 CI)
Controlled for patient (age, gender, medical
hx)and arrest (initial rhythm, cause of arrest,
time-to-defibrillation) factors. Van Walraven et
al. Ann Emerg Med 199832544.
41
Lidocaine in VF/VTCardiac Arrest
PRO
CON

• One fair level 4
• One fair level 6
• Fair human/animal level 7
• Current practice level 8

• One excellent level 2
• Two good level 2
• One fair level 3
• Two good level 4
• Eight good level 6
• Three good level 7

Net Class Indeterminate
42
Ventricular Fibrillation
OLD
NEW
VF/VT
VF/VT
Primary ABCD
Shock X 3
Shock X 3
Secondary ABCD
Epinephrine
Vasopressin Class IIb or
Epinephrine Class Indeterminate
Class IIa
Shock
Shock
Lidocaine Bretylium MgSO4 Procainamide High Dose
Epi
Class IIa
Amiodarone MgSO4 Procainamide Lidocaine High
Dose Epi
Class IIb
Class IIb
Class Indeterminate
43
Amiodarone
STRUCTURE
44
Amiodarone
HISTORY

• 1962 - discovered in Belgium

• 1967 - 1st report of clinical antianginal
  properties

• 1974 - 1st report of antiarrhythmic properties
• in oral form

• 1986 - oral formulation approved for severe
• ventricular arrhythmias

• 1995 - approved in US for IV administration in
• unstable VT/VF

45
Quality and Level of Evidence AnalysisAmiodarone
in VF/VT Cardiac Arrest
Author year (n)
1. AnastasiNana 94 (16) 2. Drexler
(14) 3. Fain 87 (12) 4. Helmy 88
(46) 5. Horowitz (5) 6. Kentsch 88
(20) 7. Klein (13) 8. Kowey 95
(228) 9. Kudenchuk 99 (504) 10. Levine 96
(273) 11. Mooss (35) 12. Morady (15) 13. Nalos
91 (22) 14. Ochi (22) 15. Rosalion 91
(23) 16. Saksena (9) 17. Scheinman 95
(342) 18. Schutzenberger 89 (26) 19. Zhou 98
(24)
9
8
Excellent
Good
1, 3
15
Supporting
Fair
2, 4, 5, 7 11, 12, 13 14, 16, 18
6
8
7
6
5
4
3
2
1
Fair
Good
Neutral/Opposing
10 17
19
Excellent
8
7
6
5
4
3
2
1
Level
46
ARREST Trial Design

• Objective
• Comparison of 1992 ACLS Guidelines with and
  without IV amiodarone in shock-refractory VT/VF
  cardiac arrest
• Methods
• Double-blind RCT (n504)
• Randomization to 300 mg amiodarone or placebo
• Amiodarone dosing
• Rapid bolus of 300 mg vial diluted with D5W to a
  volume of 20 mL in sterile syringe

47
ARREST Trial Algorithm
VF or Pulseless VT
Shock X 3
Persistent or Recurrent VF/VT
Asystole or PEA
Stable Rhythm

• ETT
• IV
• Epi

Placebo
Excluded From Study
Study Drug
Amiodarone
Standard ACLS Care
48
Amiodarone for Cardiac Arrest Benefit by
Subgroups
Statistically significant improvement across all
groups.
Amiodarone Placebo
70
64
60
49
44
50
41
38
39
34
40
33
Surviving to Admission
30
17
20
12
10
0
All Patients VF Asystole
or PEA Recurrent Persistent
Converting to VF VF
VF
Kudenchuk, et al. The ARREST Trial. NEJM, 1999.
49
Out-of-Hospital VF Cardiac Arrest
N20
Shock Lidocaine 100 mg Bicarb 1 mg/kg Shock X 2
Amiodarone 300 mg N10
Lidocaine 100 mg N10
Shocks
4.6 1.1
6.7 2.4
Plt0.05
Admitted alive to hospital
N8 (80)
Plt0.05
N2 (20)
Kentsch et al. Intensivm Medizin 19882570.
50
Amiodarone in VF/VT Caridac Arrest
PRO
CON

• One excellent level 1
• One excellent level 2
• One fair level 2
• Numerous (gt10) fair level 5
• Two good level 6
• One good level 7

• One good level 7

Net Class IIB for persistent or
recurrent VF/VT
51
Amiodarone IV
Side Effect
Incidence

• Hypotension 16.0
• Bradycardia 4.9
• Nausea 3.9
• LFT abnormalities 3.4
• Cardiac arrest 2.9
• VT 2.4
• CHF 2.1
• Fever 2.0

52
Hypotension

• Mechanism
• vasodilation
• heart block
• negative inotropicity

• Rarely a cause for discontinuing the drug

• Treatment
• slow the rate of infusion
• intravenous fluids
• vasopressor

53
Amiodarone
DOSING

• Begin with a 150 mg IV bolus over 10 min for a
  perfusing rhythm, and 300 mg IV bolus for cardiac
  arrest

• Followed by 1mg/min for 6 hrs

• Followed by 0.5 mg/min

• Breakthrough events --gt 150 mg IV boluses

• Max dose 2.1 g/24 hr

54
IV Amiodarone Dosing
Max 2.1g / 24 h
1,200
1,000
540 mg/18h
800
720 mg/24h
Total mg Dose
600
360 mg/6h
400
300 mg
200
150 mg/10min
0
Cardiac Arrest
Perfusing Rhythm
Recurrences
Maintenance
Amiodarone I.V. should, whenever possible, be
administered through a CVL, and an in-line filter
should be used during administration.

55
Tachycardia
Cardioversion
Unstable
Stable
SVT
VT
A Fib
Junctional Tach
Atrial Tach
Monomorphic
Polymorphic
A Flutter
PSVT
Wide-complex Tachycardia of Uncertain Etiology
56
Estimating Cardiac Function

• Rodriguez, et al. J Emerg Med 2000
• Human, Descriptive Study (n34)
• Physician estimates based on history, physical,
  EKG, lab tests, and X-rays
• No correlation was noted between EP estimates of
  CO and objective data obtained by esophageal
  doppler probe
• Complete disagreement with regard to low or high
  CO was noted for 21 of the paired measurements

57
Tachycardia
Cardioversion
Unstable
Stable
SVT
VT
A Fib
Junctional Tach
Atrial Tach
Monomorphic
Polymorphic
A Flutter
PSVT
Wide-complex Tachycardia of Uncertain Etiology
58
Atrial Fibrillation / Atrial Flutter
OLD
A Fib/Flutter
Diltiazem ?-Blockers Verapamil Digoxin Procainamid
e Quinidine Anticoagulants
59
Atrial Fibrillation / Atrial Flutter
OLD
NEW
A Fib/Flutter
A Fib/Flutter
Diltiazem ?-Blockers Verapamil Digoxin Procainamid
e Quinidine Anticoagulants
Normal Cardiac Fx
Impaired Cardiac Fx
WPW
RC
RC
RC Convert
Ca CB (I) ?-Blocker (I)
Amiodrn (IIb) Dig (IIb) Diltzm (IIb)
Cardioversion Amiodarone (IIb)
------------- Amiodarone (IIb) Flecainide
(IIb) Procainamide (IIb) Propafenone
(IIb) Sotalol (IIb) --------------- Adenosine
(III) Ca-/?-Blocker (III) Digoxin (III)
Convert
Convert
Cardioversion Amiodrn (IIb)
Amiodrn (IIa) Ibutilide (IIa) Flecainide
(IIa) Propafenone (IIa) Procainamide (IIa)
60
4 Clinical Features

• Patient clinically unstable?
• Cardiac function impaired?
• WPW present?
• Duration lt 48 or gt 48 hours?

61
Clinical Evaluation

• Treat unstable patients urgently
• Control the rate
• Convert the rhythm
• Provide anticoagulation

62
Tachycardia
Cardioversion
Unstable
Stable
SVT
VT
A Fib
Junctional Tach
Atrial Tach
Monomorphic
Polymorphic
A Flutter
PSVT
Wide-complex Tachycardia of Uncertain Etiology
63
Tachycardia
Cardioversion
Unstable
Stable
SVT
VT
A Fib
Junctional Tach
Atrial Tach
Monomorphic
Polymorphic
A Flutter
PSVT
Wide-complex Tachycardia of Uncertain Etiology
64
PSVT
OLD
PSVT
Vagal Maneuvers
Adenosine x 2
Narrow
Wide
QRS Width?
Blood Pressure?
Normal or elevated
Low or unstable
Lidocaine
Verapamil x 2
Procainamide
Digoxin ?-Blockers Diltiazem
Cardioversion
65
SVT
NEW
Narrow Complex SVT, stable
Vagal Maneuvers

• No DC Cardioversion
• Amiodarone
• ?-Blocker
• Ca-channel Blocker

Adenosine
Preserved
Junctional Tachycardia

• No DC Cardioversion
• Amiodarone

EF lt40, CHF

• Ca-channel Blocker
• ?-Blocker
• Digoxin
• DC Cardioversion
• Procainamide,
• amiodarone, sotalol

Preserved
PSVT

• DC Cardioversion
• Digoxin
• Amiodarone
• Diltiazem

EF lt40, CHF

• No DC Cardioversion
• Ca-channel Blocker
• ?-Blocker
• Amiodarone

Preserved
Ectopic or Multifocal Atrial Tachycardia

• No DC Cardioversion
• Amiodarone
• Diltiazem

EF lt40, CHF
66
Tachycardia
Cardioversion
Unstable
Stable
SVT
VT
A Fib
Junctional Tach
Atrial Tach
Monomorphic
Polymorphic
A Flutter
PSVT
Wide-complex Tachycardia of Uncertain Etiology
67
Simplified SVT Algorithm
68
Simplified SVT Algorithm
Stable SVT
Vagal Maneuvers Adenosine
AMIODARONE
If you are sure the patient has PSVT and
preserved cardiac function, then you should use
a Ca-channel blocker, a ?-blocker, or digoxin,
and, if unsuccessful, Cardioversion.
69
Tachycardia
Cardioversion
Unstable
Stable
SVT
VT
A Fib
Junctional Tach
Atrial Tach
Monomorphic
Polymorphic
A Flutter
PSVT
Wide-complex Tachycardia of Uncertain Etiology
70
Tachycardia
Cardioversion
Unstable
Stable
SVT
VT
A Fib
Junctional Tach
Atrial Tach
Monomorphic
Polymorphic
A Flutter
PSVT
Wide-complex Tachycardia of Uncertain Etiology
71
Ventricular Tachycardia
OLD
VT
Lidocaine
Procainamide
Bretylium
Cardioversion
72
Ventricular Tachycardia
OLD
NEW
VT
Stable VT
Lidocaine
Monomorphic VT
Polymorphic VT
Procainamide
May go directly to Cardioversion
Bretylium
Poor EF
Normal EF
Long QT
Normal QT
Cardioversion

• First-tier (IIa)
• Procainamide
• Sotalol
• Second-tier (IIb)
• Amiodarone
• Lidocaine

• Magnesium
• Pacing
• Isproterenol
• Phenytoin
• Lidocaine

• ?-Blocker
• Lidocaine
• Amiodarone
• Procainamide
• Sotalol

Impaired Cardiac Fx

• Amiodarone (IIb)
• Lidocaine (IIb)

Cardioversion
73
Procainamide vs Lidocainein Stable VT
?
?
Net conversion Procainamide (79)
Lidocaine (19)
Gorgels et al. Am J Cardiol 19967843.
74
Stable Monomorphic VT
Impaired LV EFlt40 or CHF
Preserved Cardiac Function
NOTE! May go directly to Cardioversion

• Amiodarone (IIb)
• 150 mg IV infused over 10 min,
• repeat as needed (max 2 gm/24?)
• Lidocaine (IIb)
• 0.5 to 0.75 mg/kg IV push
• Then use
• Synchronized cardioversion

• Medications any one
• Procainamide (IIa)
• Sotalol (IIa)
• Amiodarone (IIb)
• Lidocaine (IIb)

Circulation 2000102 (suppl I)I-158I-165).00
75
Tachycardia
Cardioversion
Unstable
Stable
SVT
VT
A Fib
Junctional Tach
Atrial Tach
Monomorphic
Polymorphic
A Flutter
PSVT
Wide-complex Tachycardia of Uncertain Etiology
76
Tachycardia
Cardioversion
Unstable
Stable
SVT
VT
A Fib
Junctional Tach
Atrial Tach
Monomorphic
Polymorphic
A Flutter
PSVT
Wide-complex Tachycardia of Uncertain Etiology
77
WCT of Unknown Type
OLD
WCT of uncertain type
Lidocaine
Adenosine
Procainamide
Bretylium
Cardioversion
78
WCT of Unknown Type
OLD
NEW
WCT of uncertain type
WCT of unknown type
Preserved Cardiac Fx
EF lt40, CHF
Lidocaine
Adenosine

• Cardioversion
• Procainamide
• Amiodarone

• Cardioversion
• Amiodarone

Procainamide
Bretylium
Cardioversion
79
Wide-complex Tachycardia Ineffectiveness of
Lidocaine
17 VT 3 SVT
4 VT 1 SVT
N20
N5
Recurrence
N3
Lidocaine 75400 mg
Lidocaine
N153
Net Efficacy 2/20 (10)
Armengol et al. Ann Emerg Med 198918254.
80
Tachyarrhythmic Agents
?-Blocker
Drug/Recommeded Use (Class)
Amiodarone
Ca-Blocker
Lidocaine
Magnesium
Procainamide
VF/Pulseless VT IIb
IND IND IIb
Wide-complex tachycardia IIb IIb
Stable VT IIb IIb IIa
PSVT (preserved cardiac function) IIa I
I IIa
PSVT (impaired cardiac function) IIb
Atrial fibrillation/flutter IIa I I
IIa (preserved cardiac function)
Atrial fibrillation/flutter IIb
IIb (impaired cardiac function)
Atrial fibrillation/flutter (WPW) IIb
III III IIb
Atrial fibrillation/flutter (impaired IIb ca
rdiac function plus WPW)
81
Tachyarrhythmic Agents
?-Blocker
Drug/Recommeded Use (Class)
Amiodarone
Ca-Blocker
Lidocaine
Magnesium
Procainamide
VF/Pulseless VT IIb
IND IND IIb
Wide-complex tachycardia IIb IIb
Stable VT IIb IIb IIa
PSVT (preserved cardiac function) IIa I
I IIa
PSVT (impaired cardiac function) IIb
Atrial fibrillation/flutter IIa I I
IIa (preserved cardiac function)
Atrial fibrillation/flutter IIb
IIb (impaired cardiac function)
Atrial fibrillation/flutter (WPW) IIb
III III IIb
Atrial fibrillation/flutter (impaired IIb ca
rdiac function plus WPW)
82
Tachyarrhythmic Agents
?-Blocker
Drug/Recommeded Use (Class)
Amiodarone
Ca-Blocker
Lidocaine
Magnesium
Procainamide
VF/Pulseless VT IIb
IND IND IIb
Wide-complex tachycardia IIb IIb
Stable VT IIb IIb IIa
PSVT (preserved cardiac function) IIa I
I IIa
PSVT (impaired cardiac function) IIb
Atrial fibrillation/flutter IIa I I
IIa (preserved cardiac function)
Atrial fibrillation/flutter IIb
IIb (impaired cardiac function)
Atrial fibrillation/flutter (WPW) IIb
III III IIb
Atrial fibrillation/flutter (impaired IIb ca
rdiac function plus WPW)
83
Tachyarrhythmic Agents
?-Blocker
Drug/Recommeded Use (Class)
Amiodarone
Ca-Blocker
Lidocaine
Magnesium
Procainamide
VF/Pulseless VT IIb
IND IND IIb
Wide-complex tachycardia IIb IIb
Stable VT IIb IIb IIa
PSVT (preserved cardiac function) IIa I
I IIa
PSVT (impaired cardiac function) IIb
Atrial fibrillation/flutter IIa I I
IIa (preserved cardiac function)
Atrial fibrillation/flutter IIb
IIb (impaired cardiac function)
Atrial fibrillation/flutter (WPW) IIb
III III IIb
Atrial fibrillation/flutter (impaired IIb ca
rdiac function plus WPW)
84
Tachyarrhythmic Agents
?-Blocker
Drug/Recommeded Use (Class)
Amiodarone
Ca-Blocker
Lidocaine
Magnesium
Procainamide
VF/Pulseless VT IIb
IND IND IIb
Wide-complex tachycardia IIb IIb
Stable VT IIb IIb IIa
PSVT (preserved cardiac function) IIa I
I IIa
PSVT (impaired cardiac function) IIb
Atrial fibrillation/flutter IIa I I
IIa (preserved cardiac function)
Atrial fibrillation/flutter IIb
IIb (impaired cardiac function)
Atrial fibrillation/flutter (WPW) IIb
III III IIb
Atrial fibrillation/flutter (impaired IIb ca
rdiac function plus WPW)
85
Tachyarrhythmic Agents
?-Blocker
Drug/Recommeded Use (Class)
Amiodarone
Ca-Blocker
Lidocaine
Magnesium
Procainamide
VF/Pulseless VT IIb
IND IND IIb
Wide-complex tachycardia IIb IIb
Stable VT IIb IIb IIa
PSVT (preserved cardiac function) IIa I
I IIa
PSVT (impaired cardiac function) IIb
Atrial fibrillation/flutter IIa I I
IIa (preserved cardiac function)
Atrial fibrillation/flutter IIb
IIb (impaired cardiac function)
Atrial fibrillation/flutter (WPW) IIb
III III IIb
Atrial fibrillation/flutter (impaired IIb ca
rdiac function plus WPW)
86
Other Minor Changes

• ETT Placement

• EMS EKG

• Isoproterenol

• PEA

• Biphasic (BTE) Waveform Defibrillators

87
Summary

• Amiodarone dominates the management of
  tachycardias

• Lidocaine is no longer an agent of choice for
  stable VT or for VF

• High-dose epinephrine is no longer recommended

• Vasopressin has replaced epinephrine

• Adenosine has been removed from the WCT algorithm

• Stable VT can now be managed with immediate
  cardioversion

88
Summary

• The approach to A Fib/A flutter has become more
  nuanced with attention to stability, EF, and
  duration of the arrhythmia

• Bretylium has been removed from the algorithms

• For tachyarrhythmias the focus now is on picking
  one agent (e.g. amiodarone) and sticking with it,
  instead of multiple agents used in a stepwise
  fashion (e.g. lidocaine, then procainamide, then
  bretylium, etc.).

• Isoproterenol is no longer recommended for
  bradycardia

89
Summary

• ETT placement must now be confirmed by
  nonphysical exam techniques (e.g. ETCO2 detectors)

• The prehospital ECG

• PEA

• Biphasic (BTE) Waveform Defibrillators

90
Questions?
CPR Cerebral Perfusion Resuscitation
91
Questions?
CPR Cerebral Perfusion Resuscitation
92
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93
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94
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95
Questions?
CPR Cerebral Perfusion Resuscitation
96
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