As you and your partner pull up on scene, dispatch tells you, "CPR is in progress." You grab your kit and your AED and enter the house. A man in his 30s is doing CPR on a man who appears to be in his late 60s. You call for ALS back up while your partner moves to take over CPR. She instructs the bystander to stop compressions, and she evaluates the circulation, airway and breathing (CAB). No pulse is felt, so your partner continues CPR. The bystander was doing "hands-only" CPR, but your partner begins CPR with a compression ventilation ratio of 30:2, making sure to compress the chest at least 100 times per minute and allowing for complete chest recoil.
As you open the AED and place the pads on the patient's chest, you attempt to obtain a history from the bystander, who turns out to be the patient's son. He tells you he's visiting from out of town. He says he heard a noise and found his father unresponsive this morning, so he called 9-1-1 and began chest compressions. When you inquire about advanced directives, such as a "do not resuscitate" (DNR) order, he tells you he's unaware of any such documents. With the AED in place, your partner stops CPR, the machine analyzes and reports that no shock is advised. You and your partner trade places and you immediately resume compressions, pushing hard and fast.
The AED continues to report that no shock is advised after each two-minute interval. Your partner again resumes compressions while you make a call to the hospital. You report to the emergency physician that the patient was an unwitnessed cardiac arrest, there was no return of circulation after three complete rounds of CPR, and the AED never advised that a shock was needed. The physician advises that you discontinue resuscitation attempts. Your attention now turns to caring for the son.
The New Guidelines
Every five years, the American Heart Association (AHA) releases guidelines for the care of adult and pediatric patients with cardiovascular emergencies. The 2010 change in guidelines is based on the International Liaison Committee on Resuscitation (ILCOR) consensus on CPR and ECC Science with Treatment Recommendations. The evaluation involved 356 resuscitation experts from 29 countries and produced 411 scientific reviews on 277 topics in resuscitation. The goal of the project was to provide the best care possible for patients with cardiovascular emergencies.
The importance of CPR is reinforced in the 2010 guidelines, but the initial assessment prior to CPR has been changed from ABC to CAB: circulation, airway and breathing. In the new guidelines, ventilation is deemphasized, and circulation is emphasized. If a patient doesn't have a pulse, providers should begin compressions immediately. Lay rescuers will be taught hands-only CPR, where they'll provide only compressions and no ventilations. Health-care workers will continue to provide compressions and ventilations at a 30:2 ratio and will aim to avoid interruptions in compressions as much as possible.
Providers should remember to ask about a patient's advanced directives, such as DNR orders. If DNR orders are in place, providers should make a reasonable attempt to verify the orders belong to the patient in cardiac arrest and should then stop resuscitation attempts. In the absence of advanced directives guiding such resuscitation attempts, the 2010 guidelines offer suggestions for terminating resuscitation efforts. Guided termination of resuscitation efforts in the field may "decrease the number of futile transports to the emergency department"(1). Providers need to be selective when considering the non-transport of cardiac arrest patients, so they don't compromise potentially viable patients.
The AHA suggests that if the arrest is not witnessed by EMS providers, there's no return of spontaneous circulation (ROSC) after three full rounds of CPR, and the AED doesn't recommend a shock, the BLS crew can consider terminating resuscitation efforts (2). Remember to turn your attention to the family or other bystanders on scene after resuscitation attempts have been terminated.
Cardiac arrests can be difficult calls. Everyone wants the patient to walk out of the hospital with no long-term deficits. Unfortunately, that doesn't always happen. The AHA continually evaluates the science to determine best practices in cardiovascular care to help increase survival rates. As EMS providers, whether ALS and BLS, we're obligated to remain up to date with the current standards of practice while still following local protocols.
1. Field, JM. Hazinski M, Sayre M, et al. Part 1: Executive Summary: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122:S640–S656.
2. Morrison L, Kierzek G, Diekema D, et al. Part 3: Ethics: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122:S665–S675.