New 2010 CPR guidelines

Today both the American Heart Association (AHA) and the European Resuscitation Council (ERC) have published new CPR guidelines, which determine how we will teach and perform CPR during the next five years. Both guidelines are consistent with the science in the 2010 International Consensus on CPR and ECC Science with Treatment Recommendations (CoSTR) document published by International Liaison Committee on Resuscitation (ILCOR). However, each member organization, including AHA and ERC, publish somewhat different recommendations because of geographic, economic and system differences in practice, and the availability of medical devices and drugs. We are bringing you the most important changes from the ERC compared to the old guidelines from 2005 for basic life support, electrical therapies, advance life support, and paediatric life support.

The European Resuscitation Council Guidelines for Resuscitation 2010

European Resuscitation Council

Basic life support
  • Dispatchers should be trained to interrogate callers with strict protocols to elicit information. The importance of gasping as sign of cardiac arrest is emphasised.
  • All rescuers, trained or not, should provide chest compressions to victims of cardiac arrest. A strong emphasis on delivering high quality chest compressions remains essential. The aim should be to push to a depth of at least 5 cm at a rate of at least 100 compressions min, to allow full chest recoil, and to minimise interruptions in chest compressions. Trained rescuers should also provide ventilations with a compression–ventilation (CV) ratio of 30:2. Telephone-guided chest compression-only CPR is encouraged for untrained rescuers.
  • The use of prompt/feedback devices during CPR will enable immediate feedback to rescuers and is encouraged.

ERC BLS

Electrical therapies: defibrillation, cardioversion and pacing
  • The importance of early, uninterrupted chest compressions.
  • Much greater emphasis on minimising the duration of the pre-shock and post-shock pauses; the continuation of compressions during charging of the defibrillator is recommended.
  • Immediate resumption of chest compressions following defibrillation is also emphasised. The delivery of defibrillation should be achievable with an interruption in chest compressions of no more than 5 seconds
  • The risk of harm to a rescuer from a defibrillator is very small, particularly if the rescuer is wearing gloves. The focus is now on a rapid safety check to minimise the preshock pause.
  • When treating out-of-hospital cardiac arrest, emergency medical services (EMS) personnel should provide good-quality CPR while a defibrillator is retrieved, applied and charged, but routine delivery of a pre-specified period of CPR (e.g., two or three minutes) before rhythm analysis and a shock is delivered is no longer recommended.
  • The use of up to three-stacked shocks may be considered if VF/VT occurs during cardiac catheterisation or in the early post-operative period
    following cardiac surgery. This threeshock strategy may also be considered for an initial, witnessed VF/VT cardiac arrest when the patient is already connected to a manual defibrillator.
  • Further development of AED programmes is encouraged.
Adult advanced life support
  • Increased emphasis on the use of ‘track and trigger systems’ to detect the deteriorating patient and enable treatment to prevent in-hospital cardiac arrest.
  • Increased awareness of the warning signs associated with the potential risk of sudden cardiac death out of hospital.
  • The role of the precordial thump is de-emphasised.
  • Delivery of drugs via a tracheal tube is no longer recommended – if intravenous access cannot be achieved, drugs should be given by the intraosseous (IO) route.
  • When treating VF/VT cardiac arrest, adrenaline 1 mg is given after the third shock once chest compressions have restarted and then every 3-5 minutes (during alternate cycles of CPR). Amiodarone 300 mg is also given after the third shock.
  • Atropine is no longer recommended for routine use in asystole or pulseless electrical activity (PEA).
  • Reduced emphasis on early tracheal intubation unless achieved by highly skilled individuals with minimal interruption to chest compressions.
  • Increased emphasis on the use of capnography to confirm and continually monitor tracheal tube placement, quality of CPR and to provide an early indication of return of spontaneous circulation (ROSC).
  • The potential role of ultrasound imaging during ALS is recognised.
  • Recognition of the potential harm caused by hyperoxaemia after ROSC is achieved: once ROSC has been established and the oxygen saturation of arterial blood (SaO2) can be monitored reliably (by pulse oximetry and/or arterial blood gas analysis), inspired oxygen is titrated to achieve a SaO2 of 94 – 98%.
  • Much greater detail and emphasis on the treatment of the post-cardiac arrest syndrome.
  • Recognition that implementation of a comprehensive, structured post resuscitation treatment protocol may improve survival in cardiac arrest victims after ROSC.
  • Increased emphasis on the use of primary percutaneous coronary intervention in appropriate (including comatose) patients with sustained ROSC after cardiac arrest.
  • Revision of the recommendation for glucose control: in adults with sustained ROSC after cardiac arrest, blood glucose values >10 mmol (>180 mg dl) should be treated but hypoglycaemia must be avoided.
  • Use of therapeutic hypothermia to include comatose survivors of cardiac arrest associated initially with nonshockable rhythms as well shockable rhythms. The lower level of evidence for use after cardiac arrest from nonshockable rhythms is acknowledged.
  • Recognition that many of the accepted predictors of poor outcome in comatose survivors of cardiac arrest are unreliable, especially if the patient has been treated with therapeutic hypothermia.

ERC ALS

Paediatric life support
  • Recognition of cardiac arrest – Healthcare providers cannot reliably determine the presence or absence of a pulse in less than 10 seconds in 15 infants or children. Healthcare providers should look for signs of life and if they are confident in the technique, they may add pulse palpation for diagnosing cardiac arrest and decide whether they should begin chest compressions or not. The decision to begin CPR must be taken in less than 10 seconds. According to the child’s age, carotid (children), brachial (infants) or femoral pulse (children and infants) checks may be used.
  • The compression ventilation (CV) ratio used for children should be based on whether one, or more than one rescuer is present. Lay rescuers, who usually learn only single-rescuer techniques, should be taught to use a ratio of 30 compressions to 2 ventilations, which is the same as the adult guidelines and enables anyone trained in BLS to resuscitate children with minimal additional information. Rescuers with a duty to respond should learn and use a 15:2 CV ratio; however, they can use the 30:2 ratio if they are alone, particularly if they are not achieving an adequate number of compressions. Ventilation remains a very important component of CPR in asphyxial arrests. Rescuers who are unable or unwilling to provide mouth-to-mouth ventilation should be encouraged to perform at least compression-only CPR.
  • The emphasis is on achieving quality compressions of an adequate depth with minimal interruptions to minimise no-fow time. Compress the chest to at least 1/3 of the anterior- posterior chest diameter in all children (i.e., approximately 4 cm in infants and approximately 5 cm in children). Subsequent complete release is emphasised. For both infants and children, the compression rate should be at least 100 but not greater than 120 min. The compression technique for infants includes two-finger compression for single rescuers and the twothumb encircling technique for two or more rescuers. For older children, a one- or two-hand technique can be used, according to rescuer preference.
  • Automated external defibrillators (AEDs) are safe and successful when used in children older than one year of age. Purpose-made paediatric pads or software attenuate the output of the machine to 50–75 J and these are recommended for children aged 1-8 years. If an attenuated shock or a manually adjustable machine is not available, an unmodified adult AED may be used in children older than 1 year. There are case reports of successful use of AEDs in children aged less than 1 year; in the rare case of a shockable rhythm occurring in a child less than 1 year, it is reasonable to use an AED (preferably with dose attenuator).
  • To reduce the no flow time, when using a manual defibrillator, chest compressions are continued while applying and charging the paddles or self-adhesive pads (if the size of the child’s chest allows this). Chest compressions are paused briefly once the defibrillator is charged to deliver the shock. For simplicity and consistency with adult BLS and ALS guidance, a single-shock strategy using a nonescalating dose of 4 J kg (preferably biphasic, but monophasic is acceptable) is recommended for defibrillation in children.
  • Cufed tracheal tubes can be used safely in infants and young children. The size should be selected by applying a validated formula.
  • The safety and value of using cricoid pressure during tracheal intubation is not clear. Therefore, the application of cricoid pressure should be modified or discontinued if it impedes ventilation or the speed or ease of intubation.
  • Monitoring exhaled carbon dioxide (CO2), ideally by capnography, is helpful to confirm correct tracheal tube position and recommended during CPR to help assess and optimise its quality.
  • Once spontaneous circulation is restored, inspired oxygen should be titrated to limit the risk of hyperoxaemia.
  • Implementation of a rapid response system in a paediatric inpatient setting may reduce rates of cardiac and respiratory arrest and inhospital mortality.
  • New topics in the 2010 guidelines include channelopathies and several new special circumstances: trauma, single ventricle pre and post 1st stage repair, post Fontan circulation, and pulmonary hypertension.