Podcast #238 - AHA 2020 Updates for BLS, ACLS, and PALS

Last year, the American Heart Association (AHA) provided updates to their basic life support (BLS), advanced cardiac life support (ACLS), and pediatric advanced life support (PALS) programs.  Mike Sharma is helping again by reviewing some of the key updates and changes to guidelines.  We also provide some additional feedback and information to consider with these new guidelines.

Layout of Post and Podcast:

• The full guidelines, their updates, and the cited evidence can be found with THIS LINK.
• They can also be accessed in PDF form through THIS LINK.
• Algorithms and other visuals from the AHA are placed throughout this post primarily after a related section has been discussed.
  
• Additional commentary with links (including to older podcasts), are also included.
  

Key BLS Updates:

• Chain of survival has been updated.
  • For each chain, there is now a new link for recovery.
  • Think of return of spontaneous circulation (ROSC) as the end of the beginning.
  • The adult chains of survival are below in red and the pediatric is purple.

• Adult rescue breathing has changed.
  • Now it is 1 breath every 6 seconds (10 breaths a minute).
  • There used to be ranges and it would depend on the type of airway present, but this is no longer the case.
  • See the below BLS algorithm for adults shown below.

• The type of compressions for recommended for pediatric arrest by a single rescuer has changed.
  • With a single rescuer, certain techniques were not recommended.
  • However, now the recommendation is to place two fingers, two thumbs (circling the infant), or the heel of one hand (if unable to achieve a depth of ⅓ of the chest diameter otherwise) with placement over the sternum just below the nipple line.
  • Below is the single rescuer algorithm for healthcare providers when performing pediatric BLS.

• Pediatric ventilation rates have also changed.
  • The new recommendation for pediatric patients with no normal breathing but with a pulse is to deliver 1 breath every 2-3 seconds.
  • This rate of 1 breath every 2-3 seconds is also recommended if there is an advanced airway in place.
    
  • Otherwise it would be 2 breaths every 30 compressions with a single rescuer and 2 breaths every 15 compressions with two or more rescuers.
  • It is noteworthy that this change is based on a single, observational study of 47 pediatric patients in cardiac arrest.
  • Below is the algorithm for pediatric BLS with 2 or more rescuers.

• Opioid management has been included with mention of when to administer naloxone.
  • If the patient has a pulse but is not breathing normally (absent or agonal), administer naloxone and rescue breaths.
  • However, if there is no pulse and no breathing normally, start cardiopulmonary resuscitation (CPR) and consider giving naloxone.
  • The dosing is usually between 0.4 mg and 2 mg every 2-3 minutes.

Key ACLS Updates:

• A few changes have been made specifically with the cardiac arrest algorithm with one of the most noticeable being epinephrine.
  • While the PARAMEDIC2 trial has been discussed including on TOTAL EM, the AHA is still recommending the use of epinephrine routinely in cardiac arrest.
  • However, they are now recommending early epinephrine administration for non-shockable rhythms versus waiting on epinephrine until after a second defibrillation for shockable rhythms to help emphasize the importance of defibrillation in these cases.
• Dual (or double) sequential defibrillation (DSD) has been commented on now by the AHA.
  • The AHA does not recommend its routine use.
  • DSD has been discussed on TOTAL EM before and it is worth noting that more evidence continues to be published.
• Intravenous (IV) versus intraosseous (IO) has been a topic of debate in cardiac arrest.
  • AHA is recommending that IV be the preferred route for medication administration. 
    
  • There has been some concern for decreased efficacy in IO placement, but this lacks strong evidence. 
  • AHA "believes it is reasonable for teams to first attempt IV access" in their recommendations.
  • One common approach is to attempt IV access potentially twice before moving on to IO.
• Point of care ultrasound (POCUS) for prognostication has also come under the eye of the AHA.
  • The AHA suggested against the use of POCUS for prognostication of CPR.
  • However, they specify that this does not preclude the use of ultrasound to identify potentially reversible causes of cardiac arrest or to detect ROSC.
  • This remains a point of heavy debate but worth acknowledging that POCUS is something that must be done appropriately.

• AHA has made an update with bradycardia regarding its medication dosing.
  • Atropine was to be given at 0.5 mg intervals but is now at 1 mg intervals every 3-5 minutes with a maximum amount given of 3 mg total.
  • Dopamine used to start at 2 mcg/kg/minute as an infusion but now starts at 5 mcg/kg/minute up to 20 mcg/kg/minute with this update.
  • Epinephrine remains at 2-10 mcg/minute (although this could go higher).
  • The adult bradycardia and tachycardia algorithms are both shown below since there is no change for the adult tachycardia algorithm.

• There is now an algorithm present for cardiac arrest patients who are pregnant.
  • A key reminder is that there are maternal and obstetric interventions (as detailed below).
  • It is important to recognize early the possibility of a perimortem caesarean delivery (also now referred to a resuscitate hysterotomy) may be needed and that it should be ideally performed in 5 minutes, but we must consider this as soon as the patient arrests.
  • Pregnant patients are more prone to hypoxia so oxygenation and airway management should be prioritized.
  • There is a potential for interference with maternal resuscitation if fetal monitoring is performed and it is not recommended by the AHA that fetal monitoring be performed during cardiac arrest.
  • Targeted temperature management (TTM) is recommended by the AHA during pregnancy with the fetus being continuously monitored for bradycardia as a potential complication.

• Debriefings and referral for follow up emotional support for lay rescuers, EMS providers, and hospital-based healthcare workers after a cardiac arrest event may be beneficial.
  • This is a new recommendation by the AHA with their plan being to expand on this topic in the near future.
  • A "hot offload" has been discussed on TOTAL EM with this often acting as an initial component to the debriefing system.

Key PALS Updates:

• AHA now reports that it is reasonable to choose endotracheal tubes (ETT) that are cuffed over uncuffed for intubating infants and children. 
  • Close attention should be paid to the ETT size, position, and cuff inflation pressure (usually <20-25 cm H20).
  • Several studies and systematic reviews support the safety of cuffed ETTs and demonstrate the decreased need for tube changes and reintubation.
  • Cuffed tubes may also decrease the risk for aspiration and subglottic stenosis is rare.
• Cricoid pressure is not recommended for routine use during endotracheal intubation.
  • In the 2010 update, it was commented on during that version that there was insufficient evidence to recommend routine use.
  • New studies have shown that cricoid pressure reduces intubation success rates and does not reduce regurgitation.

• An AHA update includes vascular access for neonates.
  • For neonates requiring vascular access at the time of delivery, the umbilical vein is the recommended route.
  • If IV access is not feasible, it may be reasonable to use the IO route.

• There has been a modification to the pediatric tachycardia patient with a pulse algorithm.
  • Both narrow-complex and wide-complex tachycardias are in the same algorithm.
  • This minor change does make it easier for reference purposes.

• While the AHA does report update the pediatric patient in bradycardia with a pulse algorithm, but changes are subtle.
  • The changes from 2010 are mostly in regards to the order of when steps are performed, but are all reasonable changes.
  • It is worth noting that the maximum dose of atropine has not increased from 0.5 mg to 1 mg although the adult dose is 1 mg now.

• A new checklist is present for pediatric post-arrest care.
  • This will appear similar to what we see with the adult post-arrest care.
  • It does offer reminders such as what goal blood pressure should be (maintaining a systolic blood pressure greater than the fifth percentile for age and sex).

Final Thoughts:​

• One of the mainstays is that high-quality CPR is key.
  • Compressing between a rate of 100-120 beats per minute.
  • Adequate compression depth and chest recoil.
  • High chest compression fraction (no more than 10 seconds off of the chest being key).
  • Early defibrillation if the patient is in a shockable rhythm.
• CPR Coaching is another common consideration and now encouraged.
  • Allows cognitive offloading from the team leader.
  • Can help improve the components of high-quality CPR as described above.
  • A metronome or similar device can be used to help ensure adequate compression rate.

Let us know what you think by giving us feedback here in the comments section or contacting us on Twitter or Facebook.  Remember to look us up on Libsyn and on Apple Podcasts.  If you have any questions you can also comment below, email at [email protected], or send a message from the page.  We hope to talk to everyone again soon.  Until then, continue to provide total care everywhere.

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