Current CPR Guidelines

[Guest guest]

Docs:

Good info to know on CPR.

Lyndon McGill, D.C.

Salem, Oregon

www.SalemSpineClinic.com

Evolving Doctors

The 2010 AHA Guidelines: The 4 Cs of Cardiac Arrest Care

Amal Mattu, MD

Posted: 12/30/2010

Part I: Executive Summary: 2010 American Heart Association

Guidelines for Cardiopulmonary Resuscitation and Emergency

Cardiovascular Care

Field JM, Hazinski MF, Sayre MR, et al

Circulation. 2010;122:S640-S656

The year 2010 marks the 50th anniversary of the introduction of

cardiopulmonary resuscitation (CPR). During these past 50 years,

tremendous research has been conducted to evaluate techniques,

medications, and devices designed to advance the care of victims

of cardiac arrest. The American Heart Association (AHA) developed

the first CPR guidelines in 1966 and since that time has published

frequent updates of the guidelines to help educate the public and

medical establishment about optimal care for patients with cardiac

arrest and other emergency cardiovascular conditions.

This past November, the newest set of guidelines pertaining to

CPR and emergency cardiovascular care were published by the AHA in

a supplement issue of Circulation. The guidelines

consist of 16 parts. They address not only cardiac arrest, but

also post-arrest care, dysrhythmias, acute coronary syndromes,

stroke, cardiac arrest in special situations (eg, pregnancy,

pulmonary embolism, etc), pediatric considerations, and ethics.

Part I is a summary statement of the major changes in cardiac

arrest and emergency cardiovascular care since the previous set of

guidelines, which were published in 2005. The highlights of this

"Executive Summary" are summarized below. For purposes of brevity,

this discussion will focus on adult patients with acute cardiac

conditions (cardiac arrest and dysrhythmias), excluding acute

coronary syndromes, stroke, and pediatric considerations. The

reader should note that the bulk of guideline recommendations, as

in past years, are concentrated on victims of primary cardiac

arrest and are not necessarily relevant to victims of pulmonary

arrest (eg, drowning, drug overdose, etc).

Study Summary

Change from "A-B-C" to "C-A-B." A major change in basic

life support is a step away from the traditional approach of

airway-breathing-chest compressions (taught with the mnemonic

"A-B-C") to first establishing good chest compressions ("C-A-B").

There are several reasons for this change.

Most survivors of adult cardiac arrest have an initial rhythm

of ventricular fibrillation (VF) or pulseless ventricular

tachycardia (VT), and these patients are best treated initially

with chest compressions and early defibrillation rather than

airway management.

Airway management, whether mouth-to-mouth breathing, bagging,

or endotracheal intubation, often results in a delay of

initiation of good chest compressions. Airway management is no

longer recommended until after the first cycle of chest

compressions -- 30 compressions in 18 seconds. The 30

compressions are now recommended to precede the 2 ventilations,

which previous guidelines had recommended at the start of

resuscitation.

Only a minority of cardiac arrest victims receive bystander

CPR. It is believed that a significant obstacle to bystanders

performing CPR is their fear of doing mouth-to-mouth breathing.

By changing the initial focus of resuscitation to chest

compressions rather than airway maneuvers, it is thought that

more patients will receive important bystander intervention,

even if it is limited to chest compressions.

Basic life support. The traditional recommendation of

"look, listen, and feel" has been removed from the basic life

support algorithm because the steps tended to be time-consuming

and were not consistently useful. Other recommendations:

Hands-only CPR (compressions only -- no ventilations) is

recommended for the untrained lay rescuers to obviate their

fears of mouth-to-mouth ventilations and to prevent

delays/interruptions in compressions.

Pulse checks by lay rescuers should not be attempted because

of the frequency of false-positive findings. Instead, it is

recommended that lay rescuers should just assume that an adult

who suddenly collapses, is unresponsive and not breathing

normally (eg, gasping) has had a cardiac arrest, activate the

emergency response system, and begin compressions.

Pulse checks by healthcare providers have been de-emphasized

in importance. These pulse checks are often inaccurate and

produce prolonged interruptions in compressions. If pulse checks

are performed, healthcare providers should take no longer than

10 seconds to determine if pulses are present. If no pulse is

found within 10 seconds, compressions should resume immediately.

The use of end-tidal CO2 (ETCO2)

monitoring is a valuable adjunct for healthcare professionals.

When patients have no spontaneous circulation, the ETCO2

is generally ≤ 10 mm Hg. However, when spontaneous circulation

returns, ETCO2 levels are expected to abruptly

increase to at least 35-40 mm Hg. By monitoring these levels,

interruptions in compressions for pulse checks become

unnecessary.

CPR devices. Several devices have been studied in

recent years, including the impedance threshold device and

load-distributing band CPR. No improvements in survival to

hospital discharge or neurologic outcomes have been proven with

any of these devices when compared with standard, conventional

CPR.

Electrical therapies

Patients with VF or pulseless VT should receive chest

compressions until a defibrillator is ready. Defibrillation

should then be performed immediately.

Chest compressions for 1.5-3 minutes before defibrillation in

patients with cardiac arrest longer than 4-5 minutes have been

recommended in the past, but recent data have not demonstrated

improvements in outcome.

Transcutaneous pacing of patients who are in asystole has not

been found to be effective and is no longer recommended.

Advanced cardiac life support. Good basic life support,

including high-quality chest compressions and rapid defibrillation

of shockable rhythms, is again emphasized as the foundation of

successful advanced cardiac life support. The recommendations for

airway management have undergone 2 major changes: (1) the use of

quantitative waveform capnography for confirmation and monitoring

of endotracheal tube placement is now a class I recommendation in

adults; and (2) the routine use of cricoid pressure during airway

management is no longer recommended.

As they did in 2005, the AHA acknowledges once again that as of

2010, data are "still insufficient ...to demonstrate that any

drugs improve long-term outcome after cardiac arrest."

Several important changes in recommendations for dysrhythmia

management have occurred:

For symptomatic or unstable bradydysrhythmias, intravenous

infusion of chronotropic agents (eg, dopamine, epinephrine) is

now recommended as an equally effective alternative therapy to

transcutaneous pacing when atropine fails;

As noted above, transcutaneous pacing for asystole is no

longer recommended; and

Atropine is no longer recommended for routine use in patients

with pulseless electrical activity or asystole.

Post-cardiac arrest care. Post-cardiac arrest care has

received a great deal of focus in the current guidelines and is

probably the most important new area of emphasis. There are

several key highlights of post-arrest care:

Induced hypothermia, although best studied in survivors of

VF/pulseless VT arrest, is generally recommended for adult

survivors of cardiac arrest who remain unconscious, regardless

of presenting rhythm. Hypothermia should be initiated as soon as

possible after return of spontaneous circulation with a target

temperature of 32°C-34°C.

Urgent cardiac catheterization and percutaneous coronary

intervention are recommended for cardiac arrest survivors who

demonstrate ECG evidence of ST-segment elevation acute

myocardial infarction regardless of neurologic status. There is

also increasing support for patients without ST-segment

elevation on ECG who are suspected of having acute coronary

syndrome to receive urgent cardiac catheterization.

Hemodynamic optimization to maintain vital organ perfusion,

avoidance of hyperventilation, and maintenance of euglycemia are

also critical elements in post-arrest care.

Viewpoint

The AHA 2010 guidelines represent significant progress in the

care of victims of cardiac arrest. Most important is the stronger

emphasis on post-cardiac arrest care. Induced hypothermia is

underscored, and perhaps the most important advance is

the recommendation for urgent percutaneous coronary intervention

in survivors of cardiac arrest. The wealth of data thus far

indicate that post-arrest percutaneous coronary intervention may

be the most significant advance toward improving survival and

neurologic function since defibrillation was first introduced

decades ago.

In reviewing these guidelines, I must admit, however, that I was

disappointed that AHA hesitated to adopt the concepts of

"cardiocerebral resuscitation" (CCR). CCR also promotes the

"C-A-B" approach to resuscitation, but it fosters even further

delays in airway intervention -- withholding any form of positive

pressure ventilations, in favor of persistent chest compressions,

for as long as 5-10 minutes after the cardiac arrest. The current

guidelines recommend withholding positive pressure ventilation for

a mere 18 seconds. First described in 2002,[1] CCR has

been studied more recently as well and demonstrated marked

improvements in rates of resuscitation and neurologic survival.[2-4]

I think that CCR should be incorporated into basic life support

protocols for victims of primary cardiac arrest as quickly as

possible to further improve outcomes.

Optimal management of cardiac arrest in the current decade can be

summarized simply by "the 4 Cs": Cardiovert/defibrillate,

CCR, Cooling, and Catheterization.

[Guest guest]

This AHA, as far as I know Red Cross has not adopted these guidelines. They are supposed to come out with them in the next couple months.Dr. A Caughlin DC CAC155 NW 1st Ave Day, Or. 97845 office 541-575-1063 fax 541-575-5554 From: twogems@...Date: Tue, 4 Jan 2011 15:57:32 -0800Subject: Current CPR Guidelines Docs:Good info to know on CPR.Lyndon McGill, D.C.Salem, Oregonwww.SalemSpineClinic.comEvolving DoctorsThe 2010 AHA Guidelines: The 4 Cs of Cardiac Arrest CareAmal Mattu, MDPosted: 12/30/2010Part I: Executive Summary: 2010 American Heart AssociationGuidelines for Cardiopulmonary Resuscitation and EmergencyCardiovascular CareField JM, Hazinski MF, Sayre MR, et alCirculation. 2010;122:S640-S656The year 2010 marks the 50th anniversary of the introduction ofcardiopulmonary resuscitation (CPR). During these past 50 years,tremendous research has been conducted to evaluate techniques,medications, and devices designed to advance the care of victimsof cardiac arrest. The American Heart Association (AHA) developedthe first CPR guidelines in 1966 and since that time has publishedfrequent updates of the guidelines to help educate the public andmedical establishment about optimal care for patients with cardiacarrest and other emergency cardiovascular conditions.This past November, the newest set of guidelines pertaining toCPR and emergency cardiovascular care were published by the AHA ina supplement issue of Circulation. The guidelinesconsist of 16 parts. They address not only cardiac arrest, butalso post-arrest care, dysrhythmias, acute coronary syndromes,stroke, cardiac arrest in special situations (eg, pregnancy,pulmonary embolism, etc), pediatric considerations, and ethics.Part I is a summary statement of the major changes in cardiacarrest and emergency cardiovascular care since the previous set ofguidelines, which were published in 2005. The highlights of this"Executive Summary" are summarized below. For purposes of brevity,this discussion will focus on adult patients with acute cardiacconditions (cardiac arrest and dysrhythmias), excluding acutecoronary syndromes, stroke, and pediatric considerations. Thereader should note that the bulk of guideline recommendations, asin past years, are concentrated on victims of primary cardiacarrest and are not necessarily relevant to victims of pulmonaryarrest (eg, drowning, drug overdose, etc).Study SummaryChange from "A-B-C" to "C-A-B." A major change in basiclife support is a step away from the traditional approach ofairway-breathing-chest compressions (taught with the mnemonic"A-B-C") to first establishing good chest compressions ("C-A-B").There are several reasons for this change.Most survivors of adult cardiac arrest have an initial rhythmof ventricular fibrillation (VF) or pulseless ventriculartachycardia (VT), and these patients are best treated initiallywith chest compressions and early defibrillation rather thanairway management.Airway management, whether mouth-to-mouth breathing, bagging,or endotracheal intubation, often results in a delay ofinitiation of good chest compressions. Airway management is nolonger recommended until after the first cycle of chestcompressions -- 30 compressions in 18 seconds. The 30compressions are now recommended to precede the 2 ventilations,which previous guidelines had recommended at the start ofresuscitation.Only a minority of cardiac arrest victims receive bystanderCPR. It is believed that a significant obstacle to bystandersperforming CPR is their fear of doing mouth-to-mouth breathing.By changing the initial focus of resuscitation to chestcompressions rather than airway maneuvers, it is thought thatmore patients will receive important bystander intervention,even if it is limited to chest compressions.Basic life support. The traditional recommendation of"look, listen, and feel" has been removed from the basic lifesupport algorithm because the steps tended to be time-consumingand were not consistently useful. Other recommendations:Hands-only CPR (compressions only -- no ventilations) isrecommended for the untrained lay rescuers to obviate theirfears of mouth-to-mouth ventilations and to preventdelays/interruptions in compressions.Pulse checks by lay rescuers should not be attempted becauseof the frequency of false-positive findings. Instead, it isrecommended that lay rescuers should just assume that an adultwho suddenly collapses, is unresponsive and not breathingnormally (eg, gasping) has had a cardiac arrest, activate theemergency response system, and begin compressions.Pulse checks by healthcare providers have been de-emphasizedin importance. These pulse checks are often inaccurate andproduce prolonged interruptions in compressions. If pulse checksare performed, healthcare providers should take no longer than10 seconds to determine if pulses are present. If no pulse isfound within 10 seconds, compressions should resume immediately.The use of end-tidal CO2 (ETCO2)monitoring is a valuable adjunct for healthcare professionals.When patients have no spontaneous circulation, the ETCO2is generally ≤ 10 mm Hg. However, when spontaneous circulationreturns, ETCO2 levels are expected to abruptlyincrease to at least 35-40 mm Hg. By monitoring these levels,interruptions in compressions for pulse checks becomeunnecessary.CPR devices. Several devices have been studied inrecent years, including the impedance threshold device andload-distributing band CPR. No improvements in survival tohospital discharge or neurologic outcomes have been proven withany of these devices when compared with standard, conventionalCPR.Electrical therapies Patients with VF or pulseless VT should receive chestcompressions until a defibrillator is ready. Defibrillationshould then be performed immediately.Chest compressions for 1.5-3 minutes before defibrillation inpatients with cardiac arrest longer than 4-5 minutes have beenrecommended in the past, but recent data have not demonstratedimprovements in outcome.Transcutaneous pacing of patients who are in asystole has notbeen found to be effective and is no longer recommended.Advanced cardiac life support. Good basic life support,including high-quality chest compressions and rapid defibrillationof shockable rhythms, is again emphasized as the foundation ofsuccessful advanced cardiac life support. The recommendations forairway management have undergone 2 major changes: (1) the use ofquantitative waveform capnography for confirmation and monitoringof endotracheal tube placement is now a class I recommendation inadults; and (2) the routine use of cricoid pressure during airwaymanagement is no longer recommended.As they did in 2005, the AHA acknowledges once again that as of2010, data are "still insufficient ...to demonstrate that anydrugs improve long-term outcome after cardiac arrest."Several important changes in recommendations for dysrhythmiamanagement have occurred:For symptomatic or unstable bradydysrhythmias, intravenousinfusion of chronotropic agents (eg, dopamine, epinephrine) isnow recommended as an equally effective alternative therapy totranscutaneous pacing when atropine fails;As noted above, transcutaneous pacing for asystole is nolonger recommended; andAtropine is no longer recommended for routine use in patientswith pulseless electrical activity or asystole.Post-cardiac arrest care. Post-cardiac arrest care hasreceived a great deal of focus in the current guidelines and isprobably the most important new area of emphasis. There areseveral key highlights of post-arrest care:Induced hypothermia, although best studied in survivors ofVF/pulseless VT arrest, is generally recommended for adultsurvivors of cardiac arrest who remain unconscious, regardlessof presenting rhythm. Hypothermia should be initiated as soon aspossible after return of spontaneous circulation with a targettemperature of 32°C-34°C.Urgent cardiac catheterization and percutaneous coronaryintervention are recommended for cardiac arrest survivors whodemonstrate ECG evidence of ST-segment elevation acutemyocardial infarction regardless of neurologic status. There isalso increasing support for patients without ST-segmentelevation on ECG who are suspected of having acute coronarysyndrome to receive urgent cardiac catheterization.Hemodynamic optimization to maintain vital organ perfusion,avoidance of hyperventilation, and maintenance of euglycemia arealso critical elements in post-arrest care.ViewpointThe AHA 2010 guidelines represent significant progress in thecare of victims of cardiac arrest. Most important is the strongeremphasis on post-cardiac arrest care. Induced hypothermia isunderscored, and perhaps the most important advance isthe recommendation for urgent percutaneous coronary interventionin survivors of cardiac arrest. The wealth of data thus farindicate that post-arrest percutaneous coronary intervention maybe the most significant advance toward improving survival andneurologic function since defibrillation was first introduceddecades ago.In reviewing these guidelines, I must admit, however, that I wasdisappointed that AHA hesitated to adopt the concepts of"cardiocerebral resuscitation" (CCR). CCR also promotes the"C-A-B" approach to resuscitation, but it fosters even furtherdelays in airway intervention -- withholding any form of positivepressure ventilations, in favor of persistent chest compressions,for as long as 5-10 minutes after the cardiac arrest. The currentguidelines recommend withholding positive pressure ventilation fora mere 18 seconds. First described in 2002,[1] CCR hasbeen studied more recently as well and demonstrated markedimprovements in rates of resuscitation and neurologic survival.[2-4]I think that CCR should be incorporated into basic life supportprotocols for victims of primary cardiac arrest as quickly aspossible to further improve outcomes.Optimal management of cardiac arrest in the current decade can besummarized simply by "the 4 Cs": Cardiovert/defibrillate,CCR, Cooling, and Catheterization.