Tzong-Luen Wang Chairman, Resuscitation Council of Asia (RCA)

CEO, National Resuscitation Council of Taiwan (NRCT) Professor, School of Medicine and Law, Fu-Jen Catholic University, New Taipei City, Taiwan

Vice superintendent, Chang Bing Show Chwang Memorial Hospital, Changhua County, Taiwan

Acknowledgement

Mayuki Aibiki

SchinichiroOhshimo

FACT 1Kyoungchul Cha

Mi Jin Lee

FACT 1Tzong-LuenWang

Chih-Hung Wang

FACT 1Ralph Cheung

Hing-Yu So

FACT 1

JRC KACPR NRCT RCHK

SRFAC TRC PHALim Swee Han Parinya Kunawut Francis :avapie

Chain of Survival

Five Chains in AHA and Four Chains in ERCOHCA and IHCA; Adult and Pediatric

Early Recognition and Call for Help Early CPR

Early Defibrillation and ALS Post-Arrest

Care

A B C D

30% 10% 10%50%

Basic Concepts

Chain of Survival

New Development from 2010 to 2015

• Adult Advanced Life Support • While these mechanical CPR devices should

not routinely replace manual chest compressions, they may have a role in circumstances where high-quality manual compressions are not feasible..

• New data did not prompt a recommendation to change practice but do provide sufficient equipoise for large RCTs to test whether advanced airways and epinephrine are helpful during CPR.

• Recent improvements in post-cardiac arrest care include further delineation of the effects, timing, and components of TTM, and awareness of the need to control oxygenationand ventilation and optimize cardiovascular function.

• Post–cardiac arrest patients should be treated with a care plan that includes TTM, but there is uncertainty about the optimal target temperature, how it is achieved, and for how long temperature should be controlled. g temperature should be controlled.

Major Changes from 2010 to 2015

• If waveform capnography not available, non-waveform carbon dioxide detector, esophageal detector device or ultrasound in addition to clinical assessment is an alternative.

• Vasopressin has been removed from drug lists for cardiac arrest.

• Use BVM, SGA or tracheal tube during CPR.

• Cardiac ultrasound may be considered as an additional diagnostic tool to identify potentially reversible causes if not interfering with standard ACLS protocol.

• Mechanical CPR devices can be considered in difficult circumstances such as limited staff numbers, transport, confined spaces, or during interventions.

• Some special resuscitation is re-emphasized.

Major Changes from 2010 to 2015

• Coronary angiogram is recommended for all patients with ST elevation or hemodynamically or electrically unstable patients without ST elevation.

• Identification and correction of hypotension is recommended in the immediate post-cardiac arrest period.

• Target temperature management with a range from 32 to 36ºC for at least 24 h and prevention of rebound fever is acceptable.

• Prognostication should be made no sooner than 72 h after TTM or ROSC.

• All patients progressing to brain death or circulatory death should be considered candidates for organ donation.

2016

ILCOR CoSTRInternational Liaison Committee on ResuscitationConsensus on Science and Treatment Recommendation for

Management of Cardiac Arrest and Related Emergencies

2017

ILCOR CoSTRInternational Liaison Committee on ResuscitationConsensus on Science and Treatment Recommendation for

Management of Cardiac Arrest and Related Emergencies

Independent Chest Compression and BVM Ventilation

AHA BLS Update 2017

30:2 With or WithoutInterruption

2018

ILCOR CoSTRInternational Liaison Committee on ResuscitationConsensus on Science and Treatment Recommendation for

Management of Cardiac Arrest and Related Emergencies

2018

ILCOR CoSTRInternational Liaison Committee on ResuscitationConsensus on Science and Treatment Recommendation for

Management of Cardiac Arrest and Related Emergencies

Anti-Arrhythmics

Chowdhury 2017 (MA)

Amiodarone=

Lidocaine

Anti-arrythmics

• Amiodarone vs. Nifekalant

Amino 2013 (MA)

Anti-arrythmics• Amiodarone vs. Nifekalant

Sato 2017 (MA)

2018

ILCOR CoSTRInternational Liaison Committee on ResuscitationConsensus on Science and Treatment Recommendation for

Management of Cardiac Arrest and Related Emergencies

E-CPR

E-CPR

E-CPR

E-CPR

E-CPR

E-CPR

• Favorable Factors

• Initial Shockable Rhythm

• Short No-Flow Time

• Low Lactate Level at Admission

E-CPR

There is inconclusive evidence to either support or refute the use of ECPR for OHCA and IHCA in adults and children. The quality of evidence across studies is very low.

Future investigations should be cautious of issues related to internal validity. Randomized clinical trials are needed to better inform clinical practice.

2019

ILCOR CoSTRInternational Liaison Committee on ResuscitationConsensus on Science and Treatment Recommendation for

Management of Cardiac Arrest and Related Emergencies

PART

Henry Wang

PART

Advanced Airways

•BVM ~ SGA ~ Intubation

•SGA for those with LOW intubation success rate

•SGA or ET for those with HIGH intubation success rate

ShockResume CPR

with compressions immediately

4．Start chest compression immediately

6．When AED arrivesAttach AED

Resume CPRwith compressions immediately

yes no

Analyze ECGShock indicated?

Continue CPR until EMS arrival or victim starts to move or breathe normally

3．Check breathingContinue monitoringWait for EMS arrival

normal breathing

1．Unresponsive

Abnormal (gasping)or absent breathing＊

RCA Adult BLS algorithm for lay rescuers (final)

＊Start chest compressionswhen not sure

5．Combine 30 chest compressions with 2 breaths

if trained, able and willing to give rescue breaths:

Shout for help

2 mins 2 mins

2. Activate EMS and get AED if availableFollow dispatcher’s instructions

・ Push hard（approximately 5cm）・ Push fast （100~120/min）・ Minimize pauses in chest compression・ Allow chest full recoil

RCA Acute Coronary Syndrome algorithm

(draft)

Shockable Rhythm?

1．Start CPRGive Oxygen

Attach monitoring/defibrillator

RCA Adult Cardiac Arrest algorithm (draft)

No Yes

Asystole/PEA VF/pulseless VT

2．CPR 2 minIV/IO access

Epinephrine every 3-5 minConsider advanced airway, capnography, POCUS

Shockable Rhythm?

5．CPR 2 minIV/IO access

Shockable Rhythm?Yes

No

7．CPR 2 minEpinephrine every 3-5 min

Consider advanced airway, capnography

Shockable Rhythm?

Yes

9．CPR 2 minAmiodarone (or Lidocaine, Nifekalant)

Treat reversible causes (5H5T)If no ROSC, Go to 2 or 3; consider eCPRIf ROSC, go to post-cardiac arrest care

No

Shockable Rhythm?

Yes

No

Yes

3.．CPR 2 minTreat reversible causes (5H5T)

NoGo to 4 or 6

Yes

4.

6.

8.

Shockable Rhythm?

1．Start CPRGive Oxygen

Attach monitoring/defibrillator

RCA Adult Cardiac Arrest algorithm (draft)

No Yes

Asystole/PEA VF/pulseless VT

2．CPR 2 minIV/IO access

Epinephrine every 3-5 minConsider advanced airway, capnography, POCUS

Shockable Rhythm?

5．CPR 2 minIV/IO access

Shockable Rhythm?Yes

No

7．CPR 2 minEpinephrine every 3-5 min

Consider advanced airway, capnography

Shockable Rhythm?

Yes

9．CPR 2 minAmiodarone (or Lidocaine, Nifekalant)

Treat reversible causes (5H5T)If no ROSC, Go to 2 or 3; consider eCPRIf ROSC, go to post-cardiac arrest care

No

Shockable Rhythm?

Yes

No

Yes

3.．CPR 2 minTreat reversible causes (5H5T)

NoGo to 4 or 6

Yes

4.

6.

8.

POCUSIV/IO

ROCPR 2007-2009

RCA Adult Tachycardia Algorithm (draft)

• Identify and treat underlying causes• Evaluate using the ABCDE approach• Give oxygen if appropriate and get IV access• Attach monitors to identify rhythm• Monitor blood pressure and oximetry• Heart rate typically ≧150/min

Broad QRS (≧0.12 second) ?

Tachycardia causingHypotension? Acute altered mental status? Signs of shock?

Ischemic chest discomfort? Acute heart failure?

Synchronized cardioversion• Consider sedation• If regular narrow complex, consider adenosine if readily

available

• Obtain IV access and 12-lead ECG if available• Consider adenosine only if regular and monomorphic• Consider antiarrhythmic infusion• Consider expert consultation

• Obtain IV access and 12-lead ECG if available• Consider vagal maneuvers• Consider adenosine if regular• Consider β-Blocker or calcium channel blocker for rate

control• Consider expert consultation

Yes

Yes

No

No

RCA Adult Bradycardia Algorithm (draft)

• Identify and treat underlying causes• Evaluate using the ABCDE approach• Give oxygen if appropriate and get IV access• Attach monitors to identify rhythm• Monitor blood pressure and oximetry• Heart rate typically <50/min

Bradycardia causingHypotension? Acute altered mental status? Signs of shock?

Ischemic chest discomfort? Acute heart failure?

Monitor and observe

No

No

Risk of asystole?• Recent asystole• Mobitz II AV block• Complete AV block with broad QRS• Ventricular pause >3 second

Consider atropine, if atropine ineffective, consider• Transcutaneous pacing, or• Dopamine infusion, or• Epinephrine infusion

Yes

Yes

Consider:• Expert consultation• Transvenous pacing

ScopingReview

SystematicReview

The objective is to include more PICOST’s to be reviewed in 2020.

Narrow PICOST Definitive Evidence.

Broader ScopeIndefinite Evidence

NEW DEVELOPMENT

CoSTR

T

Timing of Charging

New Scoping Review

DSD

Systematic Review available

Awaken during CompresNew Scoping Review

Opioid

Update 2015 CoSTR?

A

O

D

ERC

Optimal Sedation Prophylactic AntibioticsSeizure Treatment Continuous EEG

Post-Resuscitation Care

• Updates

• New Topics

Optimal BP, O2, CO2 Prognostication

Seizure Prophylaxis

ERC 2

Do We Need Post-ROSC Algorithm?

TTM

Prognostication

BBBB

AA

AA

FF

FFEE

EECC

CC

GGGGDD

DD

Post-Resuscitation Care

• Post-ROSC PCI – Update

2015 CoSTR is ongoing.

• TTM – TTM-2 study will be

published soon.

• Prognostication – New

prognostication template

completed and under

review.

GG

DD

EEBB

AAFF

CC

Post-ROSC PCI

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