2010 AHA Guidelines
What they mean for EMS providers
The 2010 American Heart Association (AHA) Guidelines for CPR and ECC (Emergency Cardiovascular Care) may jumpstart survival rates from sudden, unexpected, out-of-hospital cardiac arrest (OHCA). The dismal national average of 7–8.5% may jump to 20% or more.1–2 The established airway, breathing and circulation (ABC) mantra that has been taught for 50 years has now been replaced with a new protocol for trained rescuers: compressions, airway and breathing (CAB).
When it comes to untrained rescuers, hands-only CPR is recommended for adult OHCA patients, while conventional CPR is still recommended for children. Since continuous chest compressions (CCC) CPR was introduced at the University of Arizona, survival rates have tripled (4.7% to 17.6%) among patients with the treatable heart rhythms of ventricular fibrillation (v fib) or ventricular tachycardia (v tach) whose arrests were witnessed.3
“A community strategy of hands-only CPR should increase bystander action and improve survival from cardiac arrest,” says Arizona Medical Director Bentley Bobrow, MD.
- Start chest compressions right away for any unresponsive adult patient who isn’t breathing normally. If someone is breathing abnormally or gasping or having a seizure, begin resuscitation efforts immediately.
- Compress the chest two inches (rather than 1.5–2 inches) when helping adult patients.
- Compress the chest 1.5 inches when helping children.
- Providers should use quantitative waveform capnography for confirming and monitoring endotracheal tube placement. This is a new Class I recommendation for adult patients.
Emphasis have been increased on identifying weak links in the chain of survival that account for great variations in survival rates and teamwork.
The following have been de-emphasized: drugs, mechanical CPR devices and pulse checks. And the following are recommended: real-time monitoring and optimization of CPR and use of adenosine and chronotropic agents for diagnosis and treatment of certain heart rhythms. Atropine for routine treatment of pulseless electrical acitivity and asystole is no longer recommended. Neither is the routine use of cricoid pressure during airway management.
Post Resuscitation Care
This is now considered the fifth link in the chain of survival. Emphasis has been increased on the use of mild therapeutic hypothermia for comatose adult victims to improve neurological recovery.
All in all, the 2010 Guidelines could herald an unprecedented breakthrough in survival rates. “Starting CPR with chest compressions means that CPR is simpler than ever,” says Emergency Cardiovascular Care Committee Chair Michael R. Sayre, MD. “It’s never been easier to help save a life.”
- Weisfeldt ML, Sitlani CM, Ornato JP, et al. Survival after application of automatic external defibrillators before arrival of the emergency medical system: Evaluation in the resuscitation outcomes consortium population of 21 million. J Am Coll Cardiol. 2010;55:1713–1720.
- Division for Heart Disease and Stroke Prevention. www.cdc.gov/dhdsp/
- Bobrow B, Clark L, Ewy G, et al. Minimally interrupted cardiac eresuscitation by emergency medical services for out-of-hospital cardiac arrest JAMA. 2008;299:1158–1165.
- Look for a comprehensive 44-page supplement on the new guidelines in the
January 2011 issue of JEMS.
MCI in a Can
Hospital emergency departments and EMS professionals around the country are finding an increasing number of highly intoxicated teens and twentysomethings thanks to a boom in the use of energy drinks laced with caffeine and alcohol.
The drinks have become the go-to option for new drinkers looking for a quick buzz from the high alcohol content. The result, however, has been some patients registering near-lethal blood alcohol levels.
“We’ve seen clusters of it,” says Edward T. Dickinson, MD, NREMT-P, FACEP, JEMS medical editor and associate professor of emergency medicine at the Hospital of the University of Pennsylvania. “It’s clearly showing up on college campuses, and the people using it are the classic novice drinkers.”
The most visible brand is Four Loko, which has been linked to a handful of high-profile alcohol-related cases. For example, Ramapo College in Mahwah, N.J., banned the energy drinks after six students were taken to the hospital, one of which claimed to have consumed three cans of Four Loko and several shots of tequila in one hour.
The primary challenge with energy drinks containing caffeine and alcohol is that each 23.5-ounce can of Four Loko has a 12% alcohol content—about the equivalent of five or six cans of beer—and as much caffeine as a cup of coffee. But people drink it the same way.
“They drink it like they’re drinking soda, rather than drinking martinis at the bar,” says Matthew Weissman, MD, MBA, FAAP, medical director at the Ryan-NENA Community Health Center in New York City.
And that can present a multitude of challenges for EMS responders.
“From an EMS standpoint, you’re more likely to see people with altered mental status changes, unresponsive and some in respiratory failure,” says Weissman.
The increased alcohol and caffeine content override some of the physical factors that stop someone from drinking too much.
So far, the instances with the drinks have involved multiple patients, which Dickinson warned could lead EMS responders down the wrong path. “These things tend to occur in groups,” he says. “But there are other reasons the kids could be unresponsive. Make sure it’s not something like carbon monoxide.”
—Richard Huff, NREMT-B
Care Outside Your State
Imagine you’re returning from an out-of-state critical care transport and encounter a motor vehicle collision on a rural stretch of highway. You’re first on scene, and you identify multiple injuries. You call 9-1-1. You and your partner, both paramedics certified in your home state, approach the vehicle with your jump kit. Several patients need emergency care. Can you legally help them? Can you use your ALS skills if needed? What liability could you have if you treat a patient outside your jurisdiction?
Of course, providing emergency assistance is the right thing to do. Common sense should prevail, and you should do what a “reasonable paramedic would do given the same or similar situation”—that’s the standard of care to follow to avoid negligence.
These tips are for dealing with out-of-state emergencies, which pose a unique challenge for field providers:
1. Plan ahead. Your agency should have a policy or protocol in place for how to handle these situations. Ensure you know your agency’s policy before you go out of state.
2. Consult your medical director. This is a medical issue, and you should have approval of your medical director with respect to extent of care and treatment you may provide.
3. Check state law. Some states might allow for you to function across state lines through reciprocity agreements, especially in emergency situations. Check to see if a regulation or policy in both states addresses this situation.
4. Use common sense. Do what’s right for the patient, and don’t let concern for personal liability overshadow the patient’s needs. Ask yourself, “What would the public expect of me in this situation?” Because at the end of the day, a jury of the public would ultimately judge your actions. If no one else is available to provide care, do what’s best for the patient; treat and stabilize the best you can before local help arrives. Courts are more understanding of your actions when you act to the best of your ability in an emergency.
5. Limit your care to BLS. This is the safest course to follow, because the regulations for paramedics to function are very specific to the particular EMS system. While limiting your care to providing BLS until local ALS arrives, you could arguably be covered under the “Good Samaritan” provisions in that state.
6. Don’t go too far. You should always defer to the local agency EMS providers. If you know that a local EMS medic unit is just a few minutes out, attempting to perform ALS care wouldn’t make much sense. On the other hand, it makes no sense to avoid administering a lifesaving treatment, such as defibrillation when you know time is of the essence and your actions could mean the difference between life and death.
7. Document what happened. Maintain continuity of care by properly transferring care to the incoming responders. Provide them with all information about your agency, your names and your actions. Contact your supervisor and your medical director as soon as possible after the incident and complete an incident report with all the relevant details.
Remember the fundamental principle: Do no harm. Failure to act when your lack of action could harm the patient violates this principle. As long as you function at your level of certification (within your scope of practice) and don’t push the envelope, the risk of personal liability is very low in a situation in which you render appropriate assistance outside your home state when confronted with an emergency situation.
Pro Bono is written by attorneys Doug Wolfberg and Steve Wirth of Page, Wolfberg & Wirth LLC, a national EMS-industry law firm. Visit the firm’s Web site at www.pwwemslaw.com for more EMS law information.
Can’t Take the Heat
EMS providers know the feeling: You’re relaxing in the crew lounge a bad call comes in. Immediately your adrenaline starts flowing, and your heart starts pounding as you get to your ambulance. There’s no question that this is a stressor … but could it be killing us?
According to the National Fire Protection Association, 39% of the on-duty deaths involving firefighters were caused by sudden cardiac events. Although most EMS calls aren’t as physically demanding as a structure fire, the same types of physiological stresses come into play when responding to any emergency situation. Stress elevates heart rates, raises blood pressure and taxes on the body’s systems. Just like starting a cold diesel engine and running it hard is bad for your ambulance, taking your body from sitting to running is hard on it as well. The stresses for EMS responders in critical situations may be just as deadly as they are for firefighters.
EMS providers need to focus on treatment modalities that can help mitigate the effects of stress and fatigue on fellow emergency responders as well as on themselves. Rehabilitation and monitoring following work in an emergency situation is important. So is physical fitness and mitigating risk factors before the call. Encourage providers working in hot environments to remove their personal protective equipment and allow their bodies time to cool off while resting. Encourage and require crews to drop their misgivings about rest and rehabilitation periods at emergency incidents and actually allow themselves time to recover. We should all pay attention to what our bodies tell us, so we can ensure we go home safely at the end of a shift.
—Chris Kaiser, NREMT-P
This article originally appeared in December 2010 JEMS as “2010 AHA Guidelines Summary.”