Well, its about time. We’ve been like little children waiting to open our presents at Christmas.
Finally, finally, they’ve arrived.
First, of course, there was UCEM’s tried and tested rules for resuscitation. Then UCEM started exploring ways of making CPR education go viral. However, much slower to arrive have been the new guidelines sent out from the ivory towers of the International Liaison Committee on Resuscitation (ILCOR). The CoSTR 2010 highlights the scientific evidence for the new developments in resuscitation and, as always, different organisations around the world each have their own interpretations of the evidence.
So here they are then, the new resuscitation guidelines (all free to download):
- 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care (published in Circulation)
- European Resuscitation Council — ERC Guidelines for Resuscitation 2010 (full guidelines pdf here as published in Resuscitation)
- Resuscitation Council (UK) — Resuscitation Guidelines 2010
What? There’s no Australia or New Zealand? We still have to wait… Presumably this has somehow related to anomalies in the earth’s magnetic field or something — the ARC guidelines are apparently due out in December 2010. [Edit: see here for the ARC/NZRC algorithms and a link to the full guidelines.]
Don’t know where to start? The ERC’s summary of the new guidelines is well worth checking out. I really like the ERC’s flow diagrams — they’re very clear and easy on the eye. For more detail read the executive summary of the full ILCOR guidelines published in Resuscitation (CoSTR 2010).
So, what’s new?
Read on for a quick non-exhaustive and perhaps slightly biased overview of some the big ‘moves and shakes’ coming out of these guidelines, but remember the upcoming A&NZ guidelines may give different advice. Also, check out Scott Weingart’s EMCrit take on ‘what’s new’ in the AHA’s guidelines at EMCrit Podcast 34 — 2010 ACLS Guidelines.
Compressions and coronary perfusion
- Lay rescuers are advised to do compressions only (100/min to a depth of 5cm) for adult basic life support in the out-of-hospital setting (no mouth-to-mouth) and a pulse check isn’t necessary — just start if the patient is unresponsive and not breathing normally. If in doubt, start compressions!
- The alphabet is being re-written! Rescuers ‘may consider’ starting with compressions… ABC becomes CAB. The ratio is still 30:2 compressions:breaths.
- We should probably be placing intra-arterial lines while CPR is in progress (preferably using ultrasound guidance) — AHA guidelines aim for aortic diastolic pressure of 17 mmHg to maintain coronary perfusion (CPP = ADP – CVP). Scott Weingart advocates a higher target: 40 mmHg (17 does sound like bugger all to me…). This may help titrate the need for vasopressors (i.e. adrenaline) instead of giving it blindly every 3 to 5 minutes. In my experience an art line seems a pretty good way of distinguishing between people who can and cannot do CPR properly…
- The confusing recommendation (to me at least) of a speciﬁed period of CPR before out-of-hospital deﬁbrillation following an unwitnessed cardiac arrest has thankfully been given the boot.
- It’s still 1 shock after every 2 minutes of CPR. 150-200J for biphasic, 360J for monophasic.
- Make sure you charge the defibrillator while CPR is in progress to reduce ‘time off the chest’ when about to shock — the delivery of deﬁbrillation should be achievable with an interruption in chest compressions of no more than 5 s. ‘Time on the chest’ is of paramount importance — go hard, go fast, don’t stop!
- If the ‘compressionist’ is wearing gloves and you have a biphasic defibrillator continuing CPR while defibrillating is an option! There’s increasing evidence that this is safe for the ‘compressionist’.
Endotracheal tubes and airways
- Endotracheal intubation has moved further down the priority ladder, easy to place supraglottic airways like the LMA are all the rage.
- Probably best to just forget about cricoid pressure in an arrest — just do it if it helps get the tube in.
- Drugs via endotracheal tube are essentially a thing of the past — use the intraosseous route if intravenous is not an option.
- End tidal CO2 should be used to confirm ETT placement, gauge the effectiveness of CPR, help decide when to stop and to help detect return of spontaneous circulation (ROSC).
ROSC and post-cardiac arrest syndrome
- Avoid hyperoxemia following ROSC — titrate oxygen adminstration to achieve a SaO2 of 94–98%.
- There’s new stuff on the post-cardiac arrest syndrome…
- There’s more support for taking ROSC patients to the cath lab.
- We should use therapeutic hypothermia in ROSC patients regardless of whether the cardiac arrest involved a shockable or a non-shockable rhythm. Prognostication is tricky in patients treated with hypothermia — they might do better than you think!
- Treat a blood glucose >10 mmol/L in the ROSC patient, but avoid hypoglycemia.
- Check for signs of life, which are more important than pulses — you have a maximum of 10 seconds to decide before starting CPR.
- CPR ratio is 30:2 — same as adults — except for advanced practitioners who should do 15:2 compressions:breaths unless they are alone.
- In the newly born the CPR ratio is still 3:1 but air is preferred to oxygen.
- Go straight to 4 J/kg for defibrillation (single shock).
- AEDs are safe in children older than 1 year — use the adult machine if its all you’ve got; they’ve also been used in even younger children.
- Cuffed endotracheal tubes can be used safely (this gets the thumbs up from me).
- Precordial thump is (sadly) ‘de-emphasised’…
- Atropine is gone from the asystole/ PEA algorithm and shocks are contra-indicated.
- Atropine is still in for bradycardia, but electrical pacing is downgraded in favour of chemical pacing.
- Adenosine can be used to treat stable wide-complex tachycardias — but if they convert to sinus they could still have had VT… In stable monomorphic VT without CHF or MI, procainamide looks like the best drug option (ahead of amiodarone).
- Use bedside ultrasound to help rule out reversible causes of an arrest.
- Bascially, there is no good evidence for drugs or IV fluids in a cardiac arrest.
- Avoid routine hyperventilation — hypocapnia leads to cerebral ischemia.
Finally, EMCrit also has a great podcast (EMCrit Podcast 31 – Intra-Arrest Management) detailing a cutting edge approach to running a resus. As always, it’s highly recommended.