Now that we’ve reviewed the specific 2010 CPR Guidelines changes that affect EMS, it’s time to address ways to incorporate these changes into your protocols. In this section, we discuss recommended changes for EMS providers, lay providers, dispatchers and system administrators that you should consider for incorporation into your protocols and policies.
Setting a timeline over which EMS personnel are updated with new resuscitation protocols is a matter for local administrators to decide and is a challenge. If training occurs in sync with the two-year AHA certification cycle, then recently trained personnel might not be updated for almost two years. On the other hand, advancing the BLS and ACLS training schedule is not without cost.
It’s reasonable to consider an abbreviated, “interim” training session to update personnel but not necessarily to “recertify” them ahead of schedule. Ultimately, administrators will have to weigh all of the issues, including medico-legal ones, when determining how to balance the desire to provide optimal care with the realities of perturbing the existing training schedule.
BLS & ACLS Providers
Above all else, BLS and ACLS providers, upon arrival, should work as a team to rapidly assess the victim for responsiveness, normal breathing (gasping is not normal breathing) and a pulse. Finding none, one person should immediately start chest compressions. The other team member(s) should simultaneously build on that care by preparing to use the defibrillator (AED or other) and provide the correct amount of ventilation coordinated with ongoing chest compressions. Note: If both a manual defibrillator and an AED are available, trained rescuers should use the manual defibrillator because interruptions to CPR before and after defibrillations can be minimized.
These changes are reflected in the simplified adult BLS algorithm, which also emphasizes the two-minute cycles of the resuscitation process using an AED (see Figure 2, p. 9). Modifications to the more traditional BLS algorithm (Figure 3) also reflect the importance of prioritizing high-quality chest compressions over other actions.
Providing compressions first (“CAB”) may represent the biggest change to your EMS protocols. That’s largely because it’s a change to a 50-year-old procedure and, for some, it may also seem counterintuitive. This change is based largely on the fact that without chest compressions there’s no blood flow. Throughout the entire resuscitation, delays in and interruptions of chest compressions should be minimized.
Because your hands are immediately available, you can promptly start chest compressions, whereas ventilation and defibrillation equipment require preparation time. That time has typically resulted in delays in chest compressions and, therefore, delays in blood flow to the heart and brain. Simply put: A delay in compressions is potentially far more harmful than a delay in ventilation.
Providing high-quality compressions is also behind the recommendation that rescuers use devices that can provide real-time feedback about their CPR performance. This ensures they’re aware of any degradation in performance due to fatigue or as the result of distractions in the midst of what can be a very chaotic scene. Various options are available, but most operate as an adjunct to a defibrillator.
When ventilating the victim, the bag mask is recommended for use in multi-rescuer scenarios. Bag-mask ventilation isn’t recommended for single rescuers, because of the lengthy interruptions to compressions necessary for single rescuers to gather the equipment and get a reasonable seal using only one hand (a difficult task for most). Alternatively, you can use a barrier device for mouth-to-mouth ventilations to initiate CPR alone in a situation in which the patient would benefit from ventilation during CPR.
Rescuers must avoid excessive ventilation (including both too fast and too much ventilation). Most rescuers tend to provide excessive ventilation (rapid rate and large tidal volumes) during resuscitation, and overcoming that tendency is difficult. The rescuer or rescuers who are managing the airway and ventilation must concentrate on limiting their rate to one breath every six seconds, perhaps by counting the seconds slowly between ventilations (e.g., “1-one-thousand, 2-one-thousand, 3-one-thousand…”).
There is not enough evidence, at this time, to recommend the use of “passive ventilation” during CPR. Nonetheless, this strategy has been adopted by some EMS systems in the early stages of the resuscitation effort.(1, 2) Given that even perfect CPR delivers a limited amount of blood to the lungs, a minimal amount of gas exchange may be enough to adequately oxygenate the blood that flows through the lungs. However, no human studies have, thus far, demonstrated that this volume can provide effective exchange of air in alveoli.
As little as 30 seconds after ventricular fibrillation (VF) begins, blood flow to such organs as the brain and heart declines dramatically.(3) Therefore, rapid defibrillation is critical to saving lives from VF arrest.
Just as certain is the importance of minimizing the pause (less than 10 seconds) in chest compressions both before and after the shock. The 2010 Guidelines on defibrillation mainly reinforce the 2005 Guidelines, with a few small tweaks that acknowledge the multi-rescuer (and unpredictable) environment in which EMS providers typically operate.
One-shock protocol—The 2010 Guidelines continue to recommend that VF or pulseless VT be treated with a single shock followed by immediate chest compressions. Research since 2005 has confirmed that continuing chest compressions until just before delivery of a shock and resuming compressions immediately after that shock are critical in restoring an effective heartbeat.(2, 4, 5) The 2010 Guidelines conclude that the one-shock protocol is better than the older approach of using three stacked shocks with long pauses in compressions.
Shock early vs. shock later—If you witness a cardiac arrest, you should apply an AED or defibrillator immediately, analyze the heart rhythm and give a shock, if needed, as quickly as possible. When present, other members of your team should initiate CPR with chest compressions while the defibrillator is being readied. If VF is present for less than a few minutes, immediate defibrillation is highly effective at restoring a normal heart rhythm. However, if VF is present for more than four or five minutes, especially without bystander CPR, defibrillation often results in asystole. Clearly, asystole is not an improvement over VF.
The “shock later” strategy has been proposed to help with this problem. With this approach, you provide a period of high-quality CPR before attempting defibrillation. Some animal models of cardiac arrest suggest that providing CPR, even while VF is continuing, can be helpful in restoring much needed oxygen supplies to the heart muscle and wash out harmful metabolic wastes.(6,7) Once defibrillation is attempted, the heart muscle may be more prepared to pump blood rather than lapse into asystole.
Since publication of the 2005 Guidelines, human randomized trials have shown that both approaches to treatment of longer duration VF (shock early vs. shocking only after a period of one–three minutes of CPR) are about the same in terms of patient outcome. (8, 9) In reality, when there’s a team of at least two rescuers present, there’s an opportunity to provide some CPR prior to defibrillation, because chest compressions can be initiated by someone on the team while another attaches the AED or defibrillator pads and prepares for defibrillation.
Note: EMS medical directors will need to decide if the simplicity of a shock-early strategy outweighs any as-yet-unmeasured benefit of deliberately delivering a longer period of CPR prior to any defibrillation attempt.
Minimize pauses in compressions—Regardless of whether a shock-early or shock-later protocol is used, delivering a shock requires a short pause in chest compressions to ensure safety of the rescuer. Pausing chest compressions for as little as 10 seconds prior to defibrillation reduces the chance that the victim will develop a pulse following delivery of the shock.(4, 5) Similarly, published evidence shows that waiting more than a few seconds to resume chest compressions after the shock also reduces the chance that the victim will survive.(2, 4)
“Pit crew” technique—When a shock is needed, a practiced team of rescuers can minimize the pause in chest compressions to only a few seconds by continuing compressions while the defibrillator is charging, then stopping compressions only when the person operating the defibrillator is ready to give a shock, and then resuming compressions immediately after that shock. This can be done efficiently with a manual defibrillator or an AED used in manual mode. For technical reasons, though, this technique is not always possible when using an AED in automated mode, and users should simply follow the AED voice prompts.
Even a reduction of a few seconds in the pause for the analyze-charge-shock cycle has a significant impact on the chances of restoring a pulse.(10) In one EMS system that practices a “pit crew” technique to cardiac arrest resuscitation, more than half of cases of witnessed VF survive.(11) “Lack of circulation” or “no flow” time in a VF resuscitation attempt is a key measure of any team’s performance and review of CPR performance data and debriefing of personnel are critical to achieving maximal benefit from such strategies, over time.(12)
Defibrillation waveforms—Randomized human studies suggest that defibrillation with biphasic waveforms enhanced the short-term outcome of termination of VF, but no individual study has proven that using biphasic waveforms instead of monophasic waveforms improved survival to discharge.(13–15) The bottom line: Shocks save lives, but the newer waveforms (biphasic shocks) aren’t much better than the old ones (monophasic shocks) because the old ones were generally good enough.
Defibrillation energy—Some biphasic AEDs are designed to deliver a fixed-energy dose for each shock; others can provide escalating energy levels; manual defibrillators typically have controls for setting the energy level. Multiple prospective human clinical studies have not discovered an optimal energy level for initial or subsequent shocks, suggesting that actual differences in effectiveness between different energy levels are small or nonexistent.(14, 16, 17)
Human studies have not demonstrated evidence of harm from any biphasic waveform defibrillation energy up to 360 J.(17, 18) On the other hand, much higher energy shocks can cause injury to the heart in animal studies.(19–21)
Putting all this evidence together suggests that the energy level delivered for second and subsequent shocks should be at least equivalent to the energy level used for the first shock, and higher energy levels may be considered.
Post-Cardiac Arrest Care
Should spontaneous circulation be restored, rescuers must avoid “overbagging” a patient who still requires ventilation. Excessive ventilation volume and frequency can have adverse effects because blood flow back to the heart and flow in the coronary arteries are reduced during the phase of positive pressure that is generated in the chest cavity during bagging.
In addition, administration of oxygen in the post-resuscitation phase should be controlled to maintain oxygen saturation > 94% with the lowest required oxygen flow rate because excess oxygen can result in worse outcomes.(22) This, of course, requires that you have access to a pulse oximeter.
Acute Coronary Syndrome (ACS)
Most aspects of prehospital care of patients with STEMI remain the same in 2010. One that changed and has an impact on all BLS and ACLS providers: oxygen therapy.
For many years, all EMS professionals were taught to start oxygen on patients complaining of symptoms consistent with ACS, such as chest tightness. Recently emerging evidence suggests that oxygen is a drug that has an optimal dose range, and delivering too much oxygen is harmful to cells that are recovering from a period of time during which they were deprived of oxygen.922) The exact “sweet spot” is not (yet) known.
The bottom line: Chest tightness or pain no longer should be the sole trigger for starting oxygen. If the patient is short of breath or has an oxygen (O2) saturation below 94%, providers should start supplemental oxygen. The flow rate should be adjusted to provide the lowest oxygen flow that will maintain the O2 saturation >94%. Remember: There’s a several-minute lag after adjusting the flow of oxygen before the pulse oximeter reading will accurately reflect the effect of the adjustment.
On-scene assessment continues to focus on determining the time of symptom onset or when the patient was last known to be functioning normally, using a prehospital neurologic or stroke-assessment tool, minimizing on-scene time and providing rapid transport of patients to the nearest appropriate stroke hospital.
En route, EMS providers should continue to assess the ABCs, provide supplemental oxygen when oxygen saturation is below 94%, perform a secondary survey, assess serum blood glucose if possible, and provide prehospital notification of pending stroke patient arrival. Given the various levels of stroke care capabilities now available in many communities, triage based on stroke severity, time from onset or comorbidities may require triage to the highest stroke-capable hospital within a region.
CPR—As with adults, CPR in children and infants (not neonates) should begin with chest compressions, rather than rescue breaths (“CAB” instead of “ABC”), and there’s no need to “look, listen and feel for breathing.”
Lone rescuers should continue CPR with a compression-to-ventilation ratio of 30:2 and teams of two or more healthcare providers should continue with a ratio of 15:2. The target compression depth is now described as at least one-third the anterior-posterior diameter of the chest—about 2 inches (5 cm) for a child and 1 ½ inches (4 cm) for an infant. Unlike the 2005 recommendation, this provides a specific distance, which aids greatly in establishing an appropriate target depth on training manikins and CPR performance monitoring/feedback devices.
AEDs—Previously, no recommendation for or against use of an AED in children was made. The 2010 Guidelines now recommend that an AED equipped with a pediatric dose attenuator be used only if a manual defibrillator is not available. If no pediatric dose attenuator is available, the AED may be used without it.
Neonates (newly born)—It’s possible that you could deliver a baby or encounter a newborn baby in the course of your work in EMS. Because 90% of newly born babies will spontaneously breathe and only 1% will require resuscitation, the information most relevant to EMS is related to handling a normal birth. Of that information, only suctioning the mouth and nose has changed. That is, you should not routinely suction the mouth or nose of a newly born. Suctioning should be performed only if a baby has an obvious obstruction to spontaneous breathing or requires positive-pressure ventilation.
The current practice of performing endotracheal suctioning of nonvigorous babies with meconium-stained amniotic fluid remains the same.
Prompt assessment of the newly born and recommended interventions for those who are not at “term gestation,” aren’t crying or breathing and don’t have good muscle tone are summarized in Part 15 of the 2010 Guidelines.
Additional Information for ACLS Providers
For simplicity, the 2005 Guidelines first combined management principles of all cardiac arrest dysrhythmias into a single sequential algorithm. The 2010 Guidelines continue to promote one algorithm for all cardiac arrest patients through an even more simplified approach. This streamlined approach is presented in two versions, a linear algorithm similar in form to previous versions (Figure 5, p. 27) and a new circular algorithm that clearly emphasizes the cyclical nature of action and reassessment (Figure 6). Both versions build on the foundation of high-quality CPR.
Previous cardiac arrest algorithms assumed that CPR was effective and, therefore, focused attention on advanced procedures. The 2010 Guidelines refocus the rescuer on the principles of transforming conventional CPR into high-quality CPR because excellent ACLS depends on excellent BLS. Whether the ACLS provider has initiated CPR or joins the team after CPR is in progress, it is, above all else, their responsibility to ensure that high-quality chest compressions are continued throughout the resuscitation effort, interrupted as few times as necessary and then for only a few seconds at a time.
Airway & Ventilation
Don’t prioritize the establishment of an advanced airway over delivering high-quality compressions. A decision to place an airway shouldn’t be driven by “routine,” but by consideration of many factors, including the patient’s condition, the effectiveness of manual maneuvers to maintain an open airway, the number of rescuers present and the challenges of transport. As with any medical intervention, rescuers must carefully weigh any expected benefit of advanced airway insertion against the known risks the procedure poses.
Despite the importance that rescuers have historically placed on endotracheal intubation during the management of cardiac arrest, there’s little evidence demonstrating improvements in survival with the procedure even in systems with high first-time insertion success rates.(23, 24) In contrast, attempting to place an endotracheal tube often interrupts chest compressions, which experts acknowledge is a harmful complication. If the patient can be effectively ventilated with a bag mask, it’s reasonable for rescuers to consider delaying endotracheal intubation attempts, especially if the attempt requires an interruption in chest compressions.
Alternatively, EMS agencies should consider adding supraglottic airways to their list of resuscitation equipment. Supraglottic airway design permits insertion without direct glottic visualization, thus avoiding any interruption in chest compression. In direct comparisons, ventilation through a supraglottic airway is as effective as ventilation with a bag-mask device or through a properly placed endotracheal tube.(23, 24)
In general, routine use of cricoid pressure is not recommended. It may be used in special circumstances (e.g., viewing cords during intubation). Note: Multiple studies have shown that cricoid pressure more often obstructs the view to the cords than helps it.(25–27) If used, pressure should be adjusted, relaxed or released if it impedes ventilation or advanced airway placement. Cricoid pressure in non-arrest patients may protect from gastric inflation and aspiration during bag-mask ventilation. However, it may interfere with ventilation and placement of advanced airway.
Quantitative Waveform Capnography
The 2005 Guidelines lumped all end-tidal CO2 (PetCO2) detection devices (quantitative and qualitative) into a Class IIa recommendation for verifying proper endotracheal tube position. Since that time, the evidence overwhelmingly favors continuous waveform capnography as a standard of care.(28–32)
For EMS systems that perform endotracheal intubation but lack continuous waveform capnography, non-waveform PetCO2 detection devices provide a reasonable alternative. However, evidence suggests that colorimetric carbon dioxide detectors and non-waveform capnometers are no more accurate than auscultation and direct visualization for confirming tracheal tube position for patients suffering cardiac arrest.(30, 33–39)
Many EMS systems routinely use PetCO2 detection devices with other advanced airways and often report good results. However, no formal investigation to date confirms the utility of this technology in determining correct placement of these non-tracheal advanced airways. As a result, the 2010 Guidelines neither encourage nor discourage the use of capnography with non-tracheal advanced airways.
For the first time, the AHA guidelines make recommendations for the use of end-tidal carbon dioxide measurement for uses other than airway management. During CPR, PetCO2 levels are highly dependent on blood flow to the lungs produced by chest compressions; higher quality chest compressions deliver more blood (and more CO2) to the lungs. PetCO2 measured using quantitative waveform capnography in intubated patients, correlates well with cardiac output and coronary and cerebral perfusion pressures. Monitoring PetCO2 values during CPR, then, has the potential to guide optimization of compression rate and depth, and to detect fatigue in providers performing compressions.
Some good rules of thumb for using these devices:
• If PetCO2 is <10, it’s reasonable to consider trying to improve CPR quality by optimizing chest compression parameters (Class IIb).
• Persistently low PetCO2 values (<10 mmHg) during CPR in intubated patients suggest that ROSC is unlikely.
• If PetCO2 abruptly increases to a normal level (35–40 mmHg), it’s reasonable to consider that this is an indicator of ROSC (Class IIa).
• Administration of sodium bicarbonate and vasopressors can transiently alter PetCO2 values (bicarbonate transiently raises PetCO2 values and vasopressors transiently decrease PetCO2 values).
• The value of using quantitative waveform capnography in nonintubated patients to monitor and optimize CPR quality and detect ROSC is uncertain (Class IIb).
During resuscitation attempts of patients suffering from cardiac arrest, rescuers secure vascular access primarily for drug administration. Some inconclusive evidence suggests that medications given earlier in the resuscitation attempt may
produce better results.(40, 41) Unfortunately, there’s no evidence to support an optimal time interval after the onset of the cardiac arrest for drug administration or for a specific sequence of drugs.
IO cannulation provides quick access to the vascular space through the medullary cavity of the bone. All resuscitation drugs normally administered through an IV line can be administered through an IO line. Although IV drug administration is preferred during adult cardiac arrest resuscitation attempts, it’s reasonable for EMS medical directors to allow IO access when IV access is delayed.
PEA & Asystole
Although there’s no evidence that atropine administration is harmful for victims of pulseless electrical activity or asystole, rescuers should stop giving atropine to cardiac arrest victims to focus on more effective interventions. Atropine still has a role in the management of symptomatic bradycardia.
Atropine administration remains the initial therapy for victims suffering from symptomatic bradycardia (Figure 7), defined as acutely altered mental status, ischemic chest discomfort, acute heart failure, hypotension or other signs of shock. Historically, EMS agencies moved to immediate transcutaneous pacing (TCP) for patients who did not improve following atropine administration. There are no studies that conclusively demonstrate improved outcome for patients who receive TCP compared to drug therapy. Therefore, it’s reasonable for rescuers to select and deliver either therapy, depending on local resources.
In most cases of stable tachycardia (Figure 8, p. 33), rescuers should take the time to perform a 12-lead ECG to determine the identity of the tachyarrhythmia. This approach allows rescuers to tailor interventions to specific rhythms. When rhythm identification isn’t possible, rescuers should administer adenosine to stable patients experiencing narrow-complex tachycardia that fails to respond to vagal maneuvers. This remains unchanged from the 2005 Guidelines.
However, rescuers can now administer adenosine to regular, wide-complex, undifferentiated tachycardia. If this unidentified rhythm is actually a supraventricular tachycardia (SVT) with aberrancy, the adenosine could either temporarily slow or convert the rhythm. If the rhythm is actually ventricular tachycardia, the adenosine will likely have no effect, although it’s wise to have a defibrillator present during drug administration.
Note: Rescuers should not give adenosine to patients with an irregular wide-complex tachycardia, even if the patient appears stable. Adenosine administration in these cases could result in deterioration to ventricular fibrillation.
Acute Coronary Syndrome (ACS)
STEMI destination—One of the most important interventions EMS can make for patients with ST-segment elevation myocardial infarction (STEMI) is determining the appropriate receiving facility. EMS providers should obtain a 12-lead ECG and determine the time of onset of ACS symptoms. Clinical trials have shown improved outcomes in STEMI patients transported by EMS directly to a percutaneous coronary intervention (PCI)–capable hospital.(42, 43)
If the patient has a STEMI on ECG, it’s reasonable to transport the patient directly to a PCI facility, bypassing closer EDs as necessary as long as that will facilitate achieving a time interval between first medical contact and inflation of the PCI balloon of less than 90 minutes.
To achieve this goal, transport times need to be relatively short (i.e., less than 30 minutes) and should be based on regional EMS protocols. Notification of the chosen receiving hospital is critical in minimizing the time period from first medical contact to PCI.
Other protocols referring to STEMI include:
• Agencies should establish protocols for acquisition and interpretation of prehospital 12-lead ECGs, prompt field notification of receiving hospitals when STEMI is identified, and choice of destination hospital.
• EMS analgesia protocols should indicate that morphine continues to be indicated in STEMI when chest discomfort is unresponsive to nitrates, but should be used with caution in instable angina due to an association with increased mortality in a large registry study.(44)
• EMS protocols should indicate that a 12-lead ECG should be performed in cardiac arrest patients as soon as possible after ROSC to detect ACS or STEMI. Appropriate treatment of ACS or STEMI, including PCI or fibrinolysis, should be initiated regardless of coma.
• ACLS protocols should not allow routine administration of IV beta-blockers in the prehospital setting. IV beta-blocker therapy may be considered in specific situations, such as severe hypertension or tachyarrhythmias in patients without contraindications.
Hydroxocobalamin for smoke inhalation—Since publication of the 2005 Guidelines, a new treatment option, hydroxocobalamin, has been made available for patients with cyanide toxicity. Cyanide is a major component of fire smoke. Cyanide poisoning must be considered in victims of smoke inhalation who have hypotension, central nervous system depression or metabolic acidosis.
Patients in cardiac arrest or those presenting with cardiovascular instability caused by known or suspected cyanide poisoning should receive cyanide-antidote therapy with a cyanide scavenger (either IV hydroxocobalamin, IV sodium nitrite or inhaled amyl nitrite), followed as soon as possible by IV sodium thiosulfate.
Both hydroxocobalamin and sodium nitrite serve to rapidly and effectively bind cyanide in the serum and reverse the effects of cyanide toxicity. Because nitrites cause formation of an altered form of hemoglobin, methemoglobin, that does not deliver oxygen to the tissues and can cause blood pressure to fall, hydroxocobalamin has a safety advantage.
Sodium thiosulfate helps by detoxifying cyanide to thiocyanate. In animals, thiosulfate administration enhances the effectiveness of cyanide scavengers like hydroxocobalamin (45–48) and has been used successfully in humans with both hydroxocobalamin and sodium nitrite.(49–53) Clinically significant adverse effects of sodium thiosulfate are limited to vomiting. Therefore, based on the best evidence available, a treatment regimen of 100% oxygen and hydroxocobalamin, with or without sodium thiosulfate, is recommended for suspected cyanide poisoning.(54)
Changes to pediatric ALS recommendations were modest. The three most important are related to defibrillation dose (previously mentioned), the new definition of wide-complex tachycardia (QRS width is >0.09 second instead of >0.08 second) and cautions about inducing post-resuscitation hyperoxia (adjust the FiO2 to the minimum concentration needed to achieve arterial oxyhemoglobin saturation >94%, with the goal of avoiding hyperoxia while ensuring adequate oxygen delivery). For more details on these or any of the 2010 PALS Guidelines, refer to Part 14.
There is some evidence supporting a routine 1-minute delay in cutting the umbilical cord after a term or preterm birth where no resuscitation is necessary. The decision to implement such a protocol change should be left to local administrators.
EMS Administrators, Dispatchers & 9-1-1 Call Center Administrators
Integrated Systems of Care
A systems-based approach to improving resuscitation performance can result only from coordination of all segments of the community, starting with strategies to increase bystander action (e.g., public training and dispatcher-assisted CPR) and ending with effective post-resuscitation care in hospitals (e.g.,mild therapeutic hypothermia and PCI, when appropriate). EMS, of course, is an essential part of such an integrated system and is perfectly poised to drive its coordination.
STEMI—Development of a STEMI “system of care” begins with having effective and appropriately equipped response teams. In communities where PCI is the preferred reperfusion strategy, EMS destination protocols should permit bypassing non-PCI hospitals to transport patients directly to the nearest PCI facility in the system where time intervals between first medical contact and balloon times are <90 minutes and transport times are relatively short. On the hospital side of the process, ED protocols should clearly identify criteria for expeditious inter-facility transfer of patients by EMS to PCI facilities, including those patients who are ineligible for fibrinolytic therapy or in cardiogenic shock.
Post-resuscitation care—Compliance with current guidelines for providing effective post-resuscitation care, such as mild therapeutic hypothermia, isn’t consistent among hospitals. It’s reasonable for EMS administrators to serve as the catalyst for implementation of such therapies and to consider directing comatose, resuscitated cardiac arrest patients to facilities that demonstrate effective compliance with these treatment recommendations.
At the time of the Guidelines publication, there were insufficient data to determine the relative benefit of immediately inducing therapeutic hypothermia, even before arrival at the hospital. While it has been shown that therapeutic hypothermia is beneficial to patients after cardiac arrest, research has not yet shown whether it’s of substantial benefit to being the therapy in the prehospital setting prior to the arrival at a hospital that is capable of performing cooling soon after patient arrival. In spite of this, some systems have already adopted the practice. Surveillance data from those systems and data from ongoing controlled studies in Seattle and Australia may better resolve this important question and prompt a definitive recommendation on this matter from the AHA.
Stroke centers—Just as emphasized in the 2005 Guidelines, the 2010 Guidelines stress that not all hospitals are capable of providing emergent stroke care, resulting in missed opportunities for many patients to fully reach their recovery potential. The time to identify regional hospitals’ stroke capabilities is long before strokes occur. Regions and states are now actively surveying stroke care capabilities of hospitals within their region and defining triage protocols based on these capabilities. Patients with suspected stroke must be triaged to the most appropriate stroke-capable hospital.
Since 2005, new levels of stroke care have been established. The use of telemedicine, advanced neuroimaging and intra-arterial therapies in hospitals continue to expand at a rapid rate. In rural areas, many hospitals have become “stroke-prepared” by utilizing telemedicine to access stroke expertise.(55–57) This creates new opportunities for acute stroke care and potentially fibrinolytic therapy in previously underserved areas.
At the other end of the spectrum, within many regions of care, Comprehensive Stroke Centers (CSCs) now provide advanced care beyond that available at stroke-prepared and Primary Stroke Centers (PSCs). CSCs can utilize advanced imaging and intra-arterial recanalization therapies acutely to extend care beyond patients eligible within the 0–3 hour IV rtPA window, and provide neurosurgical care for ischemic and hemorrhagic strokes. In regions with multiple stroke-capable hospitals and transport distances that are relatively comparable, similar to the trauma model, patients with acute stroke should be triaged to the hospital with the highest stroke care capability.
Quality improvement (QI) programs—Measuring performance of all parts of an integrated system of care and the ultimate outcome of resuscitations (neurologically intact survival to discharge) is a critical component to any effort to improve the quality of resuscitation care in the community. Each part of the system should track its own performance in areas known to affect resuscitation outcomes and make appropriate changes to training and protocols, as opportunities for improvement are identified (close the “QI Loop”). Efforts should be made to share patient records between agencies and institutions to link prehospital to in-hospital care and outcomes. Note: HIPAA does allow data sharing under the umbrella of a healthcare QI program and EMS and 9-1-1 call center administrators should not shy away from establishing such programs.
Additional Information for EMS Administrators
CPR Performance Feedback Devices
Feedback devices, used during training and actual resuscitations, do improve the quality of CPR that is delivered.(12, 58–68) This function is an optional feature on some defibrillators and offers the additional advantage of recording the CPR performed for purposes of debriefing and QI. Less elaborate options are available that may or may not record performance.
Administrators should give strong consideration to including these devices in their overall resuscitation QI strategy.
If your EMS system doesn’t have 12-lead ECG capability, it should become a priority for upgrading your system. 12-lead ECG is now recommended for use in patients with symptomatic bradycardia or tachycardia, adult patients post-resuscitation and patients with a suspected acute coronary syndrome. Note: Medically directed quality assurance is recommended to monitor a prehospital 12-lead ECG program.
Quantitative Waveform Capnography
Capnography, coupled with clinical assessment, is now recommended as the most reliable method of confirming and monitoring correct placement of an endotracheal tube. In addition, the use of this technology to monitor CPR effectiveness and ROSC adds another valuable tool for optimizing delivery of CPR during a resuscitation.
Monitoring of oxygen saturation is routine in the in-hospital setting and is increasingly important for optimizing prehospital care. In the 2010 Guidelines, pulse oximetry is noted as essential for proper monitoring of post-resuscitation status of patients of all ages; resuscitating neonates; administering oxygen to ACS patients with dyspnea, hypoxemia or obvious signs of heart failure; and monitoring stroke patients. Pulse oximetry can be accomplished with stand-alone units or as options with many defibrillators or other monitoring equipment. If your system is not already equipped with pulse oximeters, consider adding them to your rigs.
It’s advisable to incorporate team training into all life support courses. In many geographies, multiple agencies are likely to converge at the scene of a medical call. It’s not always practical to cross-train with every agency, but efforts should be made to establish common protocols among agencies so as to facilitate teamwork on scene. For advanced courses, consider use of high-fidelity training manikins to better replicate actual scenarios and stimulate optimal interaction of team members.
High-quality CPR is a known determinant of survival from cardiac arrest.(2, 12, 68–78) Unfortunately, the psychomotor skills of CPR do deteriorate rapidly over time. However, it takes only a few minutes of practice every month or two to maintain those skills.
AHA recommends that skills be practiced and assessed multiple times between the biannual BLS and ACLS refresher courses, although no minimum frequency has been established. Accomplishing this in the EMS world is challenging, but not impossible if barriers to skills practice are low. That means creating opportunities for skills practice in locations where personnel already go. For station-based units, that’s easy to organize. For roaming units, skills practice might best be offered in an ED where they may already spend some “dwell time.”
Many changes to lay provider training over the past 10 years have focused on simplification of CPR instructions and improving access to CPR training. More recently, efforts have been made to encourage 9-1-1 call centers to implement dispatcher-assisted hands-only CPR protocols. Several studies indicate that dispatcher-assisted bystander CPR instructions for hands-only (compressions-only) CPR is at least as effective as instructions for chest compressions plus rescue breathing.(79, 80–82) Likewise, public awareness campaigns have been launched to communicate when and how to perform hands-only CPR.
The hope is, of course, that these efforts will lower known barriers to bystander intervention and increase the chance that someone will be pushing on the chest of cardiac arrest victims when EMS arrives. There’s some reason for hope that these strategies are having the desired impact. A recent report from Arizona describes a dramatic increase in bystander CPR in the state after five years of such efforts.(83)
As these programs spread, so will the probability that you will have a successful resuscitation. To fully leverage community efforts, though, it’s necessary to measure the incidence of bystander CPR. If you’re not already required to document this in your patient record, you should expect that you will be in the near future. Your help in tracking this piece of data is an important part of improving survival in your community.
The few changes to the First Aid recommendations in the 2010 Guidelines are all related to relatively uncommon scenarios, except for one: The recommendation for bystanders to advise people with chest pain to chew one adult (non-enteric-coated) or two low-dose “baby” aspirins could have some impact on what you encounter on scene, but this practice has, in fact, been widely publicized for several years by other organizations and may already be a common occurrence.
The most important messages we hope you take away from this supplement are that:
• The victim in cardiac arrest can tolerate delays in ventilation far better than delays in blood flow. Delivery of high-quality chest compressions with minimal interruption should be your priority when treating a cardiac arrest patient and, thus, “CAB” replaces “ABC.”
• Rescuers should train and operate as a coordinated team in carrying out a resuscitation.
• Real-time feedback from CPR monitors as well as physiologic data from quantitative waveform capnography can improve CPR performance.
• Avoid excessive ventilation during and after resuscitation.
• An increased focus has been placed on avoiding hypoxemia and hyperoxemia when treating perfusing patients. Oxygen administration should be optimized using pulse oximetry when available.
• For assessing and treating ACS patients, there should be protocols for acquisition and interpretation of prehospital 12-lead ECGs, prompt field notification of receiving hospitals when STEMI is identified, and choice of destination hospital.
• ACS patients should not routinely receive oxygen.
The 2010 AHA Guidelines for CPR and ECC reflect the continuing evolution of resuscitation science that started 50 years ago with the “birth” of CPR, but also a growing awareness that further improvements in survival will come less from technique and technology than from the integration of the core systems in our community that are so dependent on one another for success.
1. Kellum MJ, Kennedy KW, Barney R, et al. Cardiocerebral resuscitation improves neurologically intact survival of patients with out-of-hospital cardiac arrest. Ann Emerg Med. 2008;52(3):244–252.
2. Bobrow BJ, Clark LL, Ewy GA, et al. Minimally interrupted cardiac resuscitation by emergency medical services for out-of-hospital cardiac arrest. JAMA. 2008;299(10):1158–1165.
3. Berg RA, Sanders AB, Kern KB, et al. Adverse hemo-
dynamic effects of interrupting chest compressions for rescue breathing during cardiopulmonary resuscitation for ventricular fibrillation cardiac arrest. Circulation. 2001;104(20):2465–2470.
4. Rea TD, Helbock M, Perry S, et al. Increasing use of cardiopulmonary resuscitation during out-of-hospital ventricular fibrillation arrest: survival implications of guideline changes. Circulation. 2006;114(25):2760–2765.
5. Berg RA, Hilwig RW, Berg MD, et al. Immediate post-shock chest compressions improve outcome from prolonged ventricular fibrillation. Resuscitation. 2008;78(1):71–76.
6. Holmberg M, Holmberg S, Herlitz J. Incidence, duration and survival of ventricular fibrillation in out-of-hospital cardiac arrest patients in Sweden. Resuscitation. 2000;44(1):7–17.
7. Chan PS, Krumholz HM, Nichol G, et al. Delayed time to defibrillation after in-hospital cardiac arrest. N Engl J Med. 2008;358(1):9–17.
8. Jacobs IG, Finn JC, Oxer HF, et al. CPR before defibrillation in out-of-hospital cardiac arrest: a randomized trial. Emerg Med Australas. 2005;17(1):39–45.
9. Baker PW, Conway J, Cotton C, et al. Defibrillation or cardiopulmonary resuscitation first for patients with out-of-hospital cardiac arrests found by paramedics to be in ventricular fibrillation? A randomised control trial. Resuscitation. 2008;79(3):424–431.
10. Eftestol T, Sunde K, Steen PA. Effects of interrupting precordial compressions on the calculated probability of defibrillation success during out-of-hospital cardiac arrest. Circulation. 2002;105(19):2270–2273.
11. Kincaid C. The EMS Pit Crew Chief. JEMS.2010;
12. Edelson DP, Litzinger B, Arora V, et al. Improving in-hospital cardiac arrest process and outcomes with performance debriefing. Arch Intern Med. 2008;168(10):1063–1069.
13. van Alem AP, Chapman FW, Lank P, et al. A prospective, randomised and blinded comparison of first shock success of monophasic and biphasic waveforms in out-of-hospital cardiac arrest. Resuscitation. 2003;58(1):17–24.
14. Morrison LJ, Dorian P, Long J, et al. Out-of-hospital cardiac arrest rectilinear biphasic to monophasic damped sine defibrillation waveforms with advanced life support intervention trial (ORBIT). Resuscitation. 2005;66(2):149–157.
15. Schneider T, Martens PR, Paschen H, et al. Multicenter, randomized, controlled trial of 150-J biphasic shocks compared with 200- to 360-J monophasic shocks in the resuscitation of out-of-hospital cardiac arrest victims. Optimized Response to Cardiac Arrest (ORCA) Investigators. Circulation. 2000;102(15):1780–1787.
16. Walsh SJ, McClelland AJ, Owens CG, et al. Efficacy of distinct energy delivery protocols comparing two biphasic defibrillators for cardiac arrest. Am J Cardiol. 2004;94(3):378–380.
17. Stiell IG, Walker RG, Nesbitt LP, et al. BIPHASIC Trial: a randomized comparison of fixed lower versus escalating higher energy levels for defibrillation in out-of-hospital cardiac arrest. Circulation. 2007;115(12):1511–1517.
18. Higgins SL, Herre JM, Epstein AE, et al. A comparison of biphasic and monophasic shocks for external defibrillation. Physio-Control Biphasic Investigators. Prehosp Emerg Care. 2000;4(4):305–313.
19. Tang W, Weil MH, Sun S, et al. The effects of biphasic waveform design on post-resuscitation myocardial function. J Am Coll Cardiol. 2004;43(7):1228–1235.
20. Killingsworth CR, Melnick SB, Chapman FW, et al. Defibrillation threshold and cardiac responses using an external biphasic defibrillator with pediatric and adult adhesive patches in pediatric-sized piglets. Resuscitation. 2002;55(2):177–185.
21. Berg RA, Samson RA, Berg MD, et al. Better outcome after pediatric defibrillation dosage than adult dosage in a swine model of pediatric ventricular fibrillation. J Am Coll Cardiol. 2005;45(5):786–789.
22. Wijesinghe M, Perrin K, Ranchord A, et al. Routine use of oxygen in the treatment of myocardial infarction: systematic review. Heart. 2009;95(3):198–202.
23. Shy BD, Rea TD, Becker LJ, et al. Time to intubation and survival in prehospital cardiac arrest. Prehosp Emerg Care. 2004;8(4):394–399.
24. Jennings PA, Cameron P, Walker T, et al. Out-of-hospital cardiac arrest in Victoria: rural and urban outcomes. Med J Aust. 2006;185(3):135–139.
25. Hartsilver EL, Vanner RG. Airway obstruction with cricoid pressure. Anaesthesia. 2000;55(3):208–211.
26. Allman KG. The effect of cricoid pressure application on airway patency. J Clin Anesth. 1995;7(3):197–199.
27. Asai T, Goy RW, Liu EH. Cricoid pressure prevents placement of the laryngeal tube and laryngeal tube-suction II. Br J Anaesth. 2007;99(2):282–285.
28. Williamson JA, Webb RK, Cockings J, et al. The Australian Incident Monitoring Study. The capnograph: applications and limitations—an analysis of 2000 incident reports. Anaesth Intensive Care. 1993;21(5):551–557.
29. Linko K, Paloheimo M, Tammisto T. Capnography for detection of accidental oesophageal intubation. Acta Anaesthesiol Scand. 1983;27(3):199–202.
30. Grmec S. Comparison of three different methods to confirm tracheal tube placement in emergency intubation. Intensive Care Med. 2002;28(6):701–704.
31. Silvestri S, Ralls GA, Krauss B, et al. The effectiveness of out-of-hospital use of continuous end-tidal carbon dioxide monitoring on the rate of unrecognized misplaced intubation within a regional emergency medical services system. Ann Emerg Med. 2005;45(5):497–503.
32. Ko FY, Hsieh KS, Yu CK. Detection of airway CO2 partial pressure to avoid esophageal intubation. Zhonghua Min Guo Xiao Er Ke Yi Xue Hui Za Zhi. 1993;34(2):91–97.
33. Bozeman WP, Hexter D, Liang HK, et al. Esophageal detector device versus detection of end-tidal carbon dioxide level in emergency intubation. Ann Emerg Med. 1996;27(5):595–599.
34. Varon AJ, Morrina J, Civetta JM. Clinical utility of a colorimetric end-tidal CO2 detector in cardiopulmonary resuscitation and emergency intubation. J Clin Monit. 1991;7(4):289–293.
35. Ornato JP, Shipley JB, Racht EM, et al. Multicenter study of a portable, hand-size, colorimetric end-tidal carbon dioxide detection device. Ann Emerg Med. 1992;21(5):518–523.
36. MacLeod BA, Heller MB, Gerard J, et al. Verification of endotracheal tube placement with colorimetric end-tidal CO2 detection. Ann Emerg Med. 1991;20(3):267–270.
37. Bhende MS, Thompson AE. Evaluation of an end-tidal CO2 detector during pediatric cardiopulmonary resuscitation. Pediatrics. 1995;95(3):395–399.
38. Li J. Capnography alone is imperfect for endotracheal tube placement confirmation during emergency intubation. J Emerg Med. 2001;20(3):223–229.
39. Anton WR, Gordon RW, Jordan TM, et al. A disposable end-tidal CO2 detector to verify endotracheal intubation. Ann Emerg Med. 1991;20(3):271–275.
40. Dorian P, Cass D, Schwartz B, et al. Amiodarone as compared with lidocaine for shock-resistant ventricular fibrillation. N Engl J Med. 2002;346(12):884–890.
41. Kudenchuk PJ, Cobb LA, Copass MK, et al. Amiodarone for resuscitation after out-of-hospital cardiac arrest due to ventricular fibrillation. N Engl J Med. 1999;341(12):871–878.
42. Gross BW, Dauterman KW, Moran MG, et al. An approach to shorten time to infarct artery patency in patients with ST-segment elevation myocardial infarction. Am J Cardiol. 2007;99(10):1360–1363.
43. Le May MR, Davies RF, Dionne R, et al. Comparison of early mortality of paramedic-diagnosed ST-segment elevation myocardial infarction with immediate transport to a designated primary percutaneous coronary intervention center to that of similar patients transported to the nearest hospital. Am J Cardiol. 2006;98(10):1329–1333.
44. Meine TJ, Roe MT, Chen AY, et al. Association of intravenous morphine use and outcomes in acute coronary syndromes: results from the CRUSADE Quality Improvement Initiative. Am Heart J. 2005;149(6):1043–1049.
45. Hobel M, Engeser P, Nemeth L, et al. The antidote effect of thiosulphate and hydroxocobalamin in formation of nitroprusside intoxication of rabbits. Arch Toxicol. 1980;46(3–4):207–213.
46. Mengel K, Kramer W, Isert B, et al. Thiosulphate and hydroxocobalamin prophylaxis in progressive cyanide poisoning in guinea-pigs. Toxicology. 1989;54(3):335–342.
47. Friedberg KD, Shukla UR. The efficiency of aquocobalamine as an antidote in cyanide poisoning when given alone or combined with sodium thiosulfate. Arch Toxicol. 1975;33(2):103–113.
48. Hall AH, Rumack BH. Hydroxycobalamin/sodium thiosulfate as a cyanide antidote. J Emerg Med. 1987;5(2):115–121.
49. De Garbino JP, Bismuth C. [Therapeutic attitude in cyanide poisoning (author’s transl)]. Toxicol Eur Res. 1981;3(2):69–76.
50. Chen KK, Rose CL. Nitrite and thiosulfate therapy in cyanide poisoning. J Am Med Assoc. 1952;149(2):113–119.
51. Kirk MA, Gerace R, Kulig KW. Cyanide and methemoglobin kinetics in smoke inhalation victims treated with the cyanide antidote kit. Ann Emerg Med. 1993;22(9):1413–1418.
52. Espinoza OB, Perez M, Ramirez MS. Bitter cassava poisoning in eight children: a case report. Vet Hum Toxicol. 1992;34(1):65.
53. Baud FJ, Barriot P, Toffis V, et al. Elevated blood cyanide concentrations in victims of smoke inhalation. N Engl J Med. 1991;325(25):1761–1766.
54. Hall AH, Saiers J, Baud F. Which cyanide antidote? Crit Rev Toxicol. 2009;39(7):541–552.
55. Levine SR, Gorman M. “Telestroke”: the application of telemedicine for stroke. Stroke. 1999;30(2):464–469.
56. Shafqat S, Kvedar JC, Guanci MM, et al. Role for telemedicine in acute stroke. Feasibility and reliability of remote administration of the NIH stroke scale. Stroke. 1999;30(10):2141–2145.
57. LaMonte MP, Bahouth MN, Hu P, et al. Telemedicine for acute stroke: triumphs and pitfalls. Stroke. 2003;34(3):725–728.
58. Dine CJ, Gersh RE, Leary M, et al. Improving cardiopulmonary resuscitation quality and resuscitation training by combining audiovisual feedback and debriefing. Crit Care Med. 2008;36(10):2817–2822.
59. Wik L, Thowsen J, Steen PA. An automated voice advisory manikin system for training in basic life support without an instructor. A novel approach to CPR training. Resuscitation. 2001;50(2):167–172.
60. Sutton RM, Donoghue A, Myklebust H, et al. The voice advisory manikin (VAM): an innovative approach to pediatric lay provider basic life support skill education. Resuscitation. 2007;75(1):161–168.
61. Monsieurs KG, De Regge M, Vogels C, et al. Improved basic life support performance by ward nurses using the CAREvent Public Access Resuscitator (PAR) in a simulated setting. Resuscitation. 2005;67(1):45–50.
62. Beckers SK, Skorning MH, Fries M, et al. CPREzy improves performance of external chest compressions in simulated cardiac arrest. Resuscitation. 2007;72(1):100–107.
63. Wik L, Myklebust H, Auestad BH, et al. Twelve-month retention of CPR skills with automatic correcting verbal feedback. Resuscitation. 2005;66(1):27–30.
64. Spooner BB, Fallaha JF, Kocierz L, et al. An evaluation of objective feedback in basic life support (BLS) training. Resuscitation. 2007;73(3):417–424.
65. Abella BS, Edelson DP, Kim S, et al. CPR quality improvement during in-hospital cardiac arrest using a real-time audiovisual feedback system. Resuscitation. 2007;73(1):54–61.
66. Chiang WC, Chen WJ, Chen SY, et al. Better adherence to the guidelines during cardiopulmonary resuscitation through the provision of audio-prompts. Resuscitation. 2005;64(3):297–301.
67. Niles D, Nysaether J, Sutton R, et al. Leaning is common during in-hospital pediatric CPR, and decreased with automated corrective feedback. Resuscitation. 2009;80(5):553–557.
68. Kramer-Johansen J, Myklebust H, Wik L, et al. Quality of out-of-hospital cardiopulmonary resuscitation with real time automated feedback: a prospective interventional study. Resuscitation. 2006;71(3):283–292.
69. Sugerman NT, Edelson DP, Leary M, et al. Rescuer fatigue during actual in-hospital cardiopulmonary resuscitation with audiovisual feedback: a prospective multicenter study. Resuscitation. 2009;80(9):981–984.
70. Valenzuela TD, Kern KB, Clark LL, et al. Interruptions of chest compressions during emergency medical systems resuscitation. Circulation. 2005;112(9):1259–1265.
71. Abella BS, Alvarado JP, Myklebust H, et al. Quality of cardiopulmonary resuscitation during in-hospital cardiac arrest. JAMA. 2005;293(3):305–310.
72. Wik L, Kramer-Johansen J, Myklebust H, et al. Quality of cardiopulmonary resuscitation during out-of-hospital cardiac arrest. JAMA. 2005;293(3):299–304.
73. Wolfe JA, Maier GW, Newton JR, Jr., et al. Physiologic determinants of coronary blood flow during external cardiac massage. J Thorac Cardiovasc Surg. 1988;95(3):523–532.
74. Aufderheide TP, Pirrallo RG, Yannopoulos D, et al. Incomplete chest wall decompression: a clinical evaluation of CPR performance by EMS personnel and assessment of alternative manual chest compression-decompression techniques. Resuscitation. 2005;64(3):353–362.
75. Sutton RM, Maltese MR, Niles D, et al. Quantitative analysis of chest compression interruptions during in-hospital resuscitation of older children and adolescents. Resuscitation. 2009;80(11):1259–1263.
76. Sutton RM, Niles D, Nysaether J, et al. Quantitative analysis of CPR quality during in-hospital resuscitation of older children and adolescents. Pediatrics. 2009;124(2):494–499.
77. Edelson DP, Abella BS, Kramer-Johansen J, et al. Effects of compression depth and pre-shock pauses predict defibrillation failure during cardiac arrest. Resuscitation. 2006;71(2):137–145.
78. Christenson J, Andrusiek D, Everson-Stewart S, et al. Chest compression fraction determines survival in patients with out-of-hospital ventricular fibrillation. Circulation. 2009;120(13):1241–1247.
79. Svensson L, Bohm K, Castren M, et al. Compression-only CPR or standard CPR in out-of-hospital cardiac arrest. N Engl J Med.363(5):434–442.
80. Rea TD, Fahrenbruch C, Culley L, et al. CPR with chest compression alone or with rescue breathing. N Engl J Med.363(5):423–433.
81. White L, Rogers J, Bloomingdale M, et al. Dispatcher-
assisted cardiopulmonary resuscitation: risks for patients not in cardiac arrest. Circulation.121(1):91–97.
82. Hallstrom A, Cobb L, Johnson E, et al. Cardiopulmonary resuscitation by chest compression alone or with mouth-to-mouth ventilation. N Engl J Med. 2000;342(21):1546–1553.
83. Bobrow BJ, Spaite DW, Berg RA, et al. Chest compression-only CPR by lay rescuers and survival from out-of-hospital cardiac arrest. JAMA.304(13):1447–1454.
This article originally appeared in the January 2011 JEMS supplement “Evolution in Resuscitation” as “Revising Your Protocols: Steps to take to ensure you’re meeting the new Guidelines.”