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Push Hard, Fast, Deep, Continuously

For this special supplement to JEMS, we assembled some of the leading experts on cardiac care to synthesize and highlight the 2010 American Heart Association Guidelines on Cardiopulmonary Resuscitation and Emergency Cardiac Care. In addition to summarizing the important aspects of cardiac care and cardiac arrest management, the authors carefully outlined important areas that EMS agencies, tasked with implementing the Guidelines, should consider.

The new Guidelines seem simple in several areas, but, in my opinion, they’ll require us to carefully retrain our crews, adopt a new thought process and systems approach to cardiac arrest management, and develop a more integrated citizen, police, fire, EMS and hospital interface.

Key areas to note:

  • It’s critical to get on the chest of a cardiac arrest patient fast (and stay there) to keep the patient’s blood circulating via continuous, high-quality compressions. Without the need for ventilations, it should be easier to get the public “on board” with what I term the new CARE Team initiative (Compressions, AED response, Remain on the chest, Effective 2" compressions).
  • We no longer consider gasps as respirations. We should teach our personnel that the “A” in “agonal” means “almost dead.”
  • We must ensure that adult compressions are at least 2" deep, and delivered at least 100 times per minute—a deeper and faster compression regimen than we have performed in the past. In essence, we’ll have to mimic the calculated depth and rate of mechanical CPR devices and attempt to continue compressions to the optimal depth and rate as consistently as these devices do. Remember: About 65% of the population is overweight or morbidly obese, so the depth of "at least 2 inches" is especially applicable if you want to keep blood circulating to the brains of these individuals.
  • Cardiac and respiratory arrest patients must be managed in a more highly organized and coordinated manner, and the community must be more closely integrated into your EMS system than in the past.


The reality is that these are not simple tasks; they are critical tasks that will require a much more defined, practiced and coordinated approach to cardiac arrest management than we’ve used in the past. Our crews must be vigilant to avoid interrupting compressions once they start a resuscitation. That’s easier said than done.  This area will require the most practice and operational oversight to enable us to affect and improve resuscitation success rates. It’s my opinion that feedback devices and mechanical compression devices will play an important role in this area. 

Many systems have been progressive and have already been testing or have implemented most of the areas now formally recommended or sanctioned by the 2010 Guidelines. For example, systems that have implemented therapeutic hypothermia care into their treatment plans and coordinated them closely with their receiving hospitals are already achieving incredible results.

JEMS will continue to report on the successful efforts of these progressive agencies. Using the new Guidelines, follow the lead of these systems and implement procedures and processes that will give your system/agency improved resuscitation rates.



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