It had been anticipated for months and had all the excitement of a movie premiere. Manufacturers, sales representatives, authors, researchers, cardiologists, EMS administrators and their crews gathered around their computer screens awaiting the release of the 2010 American Heart Association (AHA) Guidelines for CPR and Emergency Cardiovascular Care. It’s a major event in EMS because the guidelines, and the recommendations that occur as a result of them, set the agenda for the way we train, operate, and ultimately, save patients throughout the next five years.
I, for one, was thrilled to see the allowance of manually-triggered oxygen-powered resuscitators for use in addition to bag-valve-mask resuscitators. These devices, long the mainstay of EMS resuscitation in the field, will again allow us to easily deliver 100% O2 to patients without interrupting compressions.
Because of the many recommendations, changes and explanations presented in the new guidelines, JEMS and several forward-thinking sponsors asked a team of cardiac care experts to synthesize and present the most relevant areas in a special, easy-to-read editorial supplement you’ll receive with your January issue of JEMS. This report will also offer implementation recommendations.
For example, the new guidelines not only recommend that EMS medical directors consider
implementing post-arrest therapeutic hypothermia protocols, but also present the temperature at which your IV fluids should be chilled and maintained prior to use.
They also recommend EMS medical directors coordinate with receiving hospitals to ensure resuscitated patients are taken to a facility that’s capable of continuing the therapeutic hypothermia efforts in their emergency department (ED) and critical-care units. This is true “closing-the-loop” thinking for which the AHA should be commended.
The theme of the 2010 guidelines is that compressions should be started early and maintained with minimal interruptions throughout the care of cardiac arrest patients. A special monograph, which will be included in the December issue of JEMS, will
present evidence and references that clearly illustrate the importance of delivering quality CPR to your patients.
The only disappointment I had with the new guidelines was their failure to “recommend” the use of mechanical CPR devices in the field—saying there was “not enough evidence” to recommend their use. This doesn’t mean they cannot or should not be used, but that they feel there are not enough controlled studies that show their benefit.
We went through that phase with compressions-first and compressions-only CPR five years ago when only a few pioneering EMS systems moved ahead by adopting and implementing adult intraosseous infusion, continuous compression CPR, 9-1-1 advice to callers to do compressions-only CPR and use of therapeutic hypothermia in the field—before they also were “recommended.”
I believe we’ll see the most innovative and forward-thinking EMS systems using mechanical CPR to attain the objectives of the 2010 guidelines for consistent and minimally-interrupted compressions, just as they’re now doing by deploying provider feedback devices in the field to enhance the quality of their compressions.
You see, some things are just intuitive. There’s no way to maintain consistent, minimally interrupted CPR in the field without the use of a mechanical device. We’ve been kidding ourselves for decades on this one. If you honestly analyze interruption periods during your resuscitation efforts, I think you’ll find the following compression time losses:
- 10 seconds are lost to lift and move the patient to a firm surface.
- 10 seconds are lost to place and secure the patient onto a transfer device.
- 50 seconds are lost during rescuer compressor switches at a code, calculated based on this occurring (as recommended) every two minutes (estimated as 10 times during a 20-minute resuscitation = 10 x 5 seconds).
- 20 seconds are lost while attempting to intubate the patient.
- 180 seconds (minimum) are lost during removal of a patient from the second floor of a home. This estimate includes 30 seconds to secure, lift and move an adult patient through at least one doorway, down a hallway to a stairway. Then add in 60 seconds (I’m being generous) to carry them down a flight of steps. Add another 90 seconds to get them through the front door, down a set of front steps, across an uneven walkway, and in between cars at the curb. This also includes transfer over to the stretcher, cot raising and loading into the ambulance, as well as the delay in getting a person back on the chest.
- 100 seconds (minimum) are lost during removal of the patient, movement into the ED and transfer over to the hospital’s gurney.
And, for the record, performing quality manual CPR consistently in a moving ambulance can’t be done, so we could also add 600 seconds of “interrupted” compressions.
You can try to argue that your system isn’t guilty of any of these 370–970 second delays in patient compression (and patient care) and that you don’t transport pulseless patients can’t be resuscitated on scene, but you are, or will be, incorrect because I believe we’ll see more asystolic codes being transported and successfully resuscitated in the hospital in the future—particularly with therapeutic hypothermia resuscitation.
You’ll have to wait for the 2015 guidelines to truly prove me wrong on that one. In the meantime, look for the compelling article by Angelo Salvucci, MD, FACEP, in the December cardiac care issue of JEMS to understand why we’re seeing more asystole and fewer v fib cases in the field. JEMS
This article originally appeared in November JEMS as “You Gotta Have Heart: New AHA guidelines set the pace for CPR.”