For this special section of JEMS, committee chairs and key authors of the 2015 American Heart Association (AHA) Guidelines Update for CPR and Emergency Cardiovascular Care (ECC) synthesize and summarize the key changes, deliberations, considerations, research and recommendations as they relate to EMS and the EMS-hospital interface.
The 2015 Guidelines Update focuses on topics with significant new science or ongoing controversy, and so serves as an update to the 2010 guidelines rather than a complete revision. It also marks the beginning of a new era, because the guidelines will transition from a five-year cycle of periodic revisions and updates to a Web-based format that’s continuously updated by using an evidence evaluation process to facilitate more rapid translation of new scientific discoveries into daily patient care. The first release is available at http://eccguidelines.heart.org and is based on the comprehensive 2010 Guidelines plus the 2015 update.
What hasn’t changed is the emphasis on optimizing the system of care for out-of-hospital cardiac arrest, emphasizing measurement of process and outcomes as a foundation for continuous quality improvement.
BLS & CPR Quality: There’s a new recommendation to consider use of social media to summon rescuers who are willing and able to perform CPR and are in close proximity to someone with a suspected cardiac arrest. Dispatcher-assissted CPR recommendations were also strengthened.
Notable changes in BLS include new upper limits for compression rate (100–120/min) and compression depth (5–6 cm). New data continues to indicate mechanical CPR isn’t superior to manual CPR and thus isn’t recommended for routine use. It’s noted, however, that it might be beneficial in special circumstances.
The use of the impedance threshold device alone during CPR isn’t recommended based on the neutral results of a large multicenter trial. However, the use of the ITD combined with active compression-decompression CPR may be considered as an alternative to standard CPR based on the potential for improved survival with good neurologic function.
Advanced Cardiovascular Life Support (ACLS): There are limited changes in ACLS care during cardiac arrest. Recommendations for defibrillation are unchanged. Review of existing data demonstrated no superiority of bag-valve mask ventilation, supraglottic airways or endotracheal (ET) intubation as strategies for airway management and ventilation during CPR.
Although waveform capnography remains the recommended strategy for confirmation of ET tube placement during CPR, ultrasound has been added as an alternative strategy when capnography isn’t available.
The use of vasopressors during CPR was extensively reviewed, resulting in the removal of vasopressin from the ACLS algorithm based on lack of evidence for additional benefit compared to standard dose epinephrine therapy alone. It’s also now recommended that epinephrine, when used, should be administered as soon as feasible in patients with non-shockable rhythms.
Although there were no new recommendations on the use of physiologic monitoring or ultrasound to guide resuscitation during cardiac arrest, the inability to achieve an end-tidal carbon dioxide value ≥ 10 mmHg in intubated patients after 20 minutes of CPR has been added a potential component of a multimodal criteria to guide the decision to terminate of resuscitation efforts.
Finally, the Guidelines restated that the use of extracorporeal cardiopulmonary resuscitation as a rescue therapy for refractory cardiac arrest may be considered when the suspected etiology of the cardiac arrest is potentially reversible during a limited period of mechanical cardiorespiratory support. However, implementation of such a strategy is resource intensive and requires a highly coordinated system of care to be successful.
Post-Cardiac Arrest Care: The most important change in post-cardiac arrest care is in targeted temperature management. Based on the results of major prospective randomized clinical trials, the target temperature range has been expanded to 32–36 degrees C, and the use of rapidly infused cold saline in the prehospital setting isn’t recommend due to lack of impact on patient outcomes. The importance of early coronary angiography in patients with and without STEMI criteria is also further emphasized.
Pediatric BLS & ACLS: Pediatric guidelines were updated with limited changes and, in most cases, mirror changes in the adult guidelines. New algorithms for single-rescuer and multiple-rescuer pediatric healthcare-provider CPR were created. The upper limits of chest compression rate and depth recommended in adult BLS were also applied to adolescents.
Atropine is no longer recommended for routine use as an adjunctive therapy during ET intubation to prevent bradycardia, but could be considered in patients at high risk for bradycardia.
Finally, amiodarone or lidocaine are considered equally acceptable for the treatment of shock-refractory v fib or pulseless v tach in children.
Special Circumstances: The most notable change here is the recommendation for non-healthcare BLS providers to administer naloxone in patients with suspected opioid overdose.
Recommendations to consider IV lipid therapy have been expanded from cardiac arrest caused by local anesthetic overdose to cardiac arrest caused by drug toxicity. Finally, left uterine displacement is strengthened as the primary strategy for aortocaval decompression during cardiac arrest in pregnancy.
Conclusion: Overall, the 2015 AHA Guidelines continue to refine our resuscitation strategies based on available new evidence. Successful resuscitation depends on coordinated systems of care that start with prompt rescuer actions and delivery of high-quality CPR, continued through optimized ACLS and post-cardiac arrest care. Systems that monitor and report quality of care metrics and patient-centered outcomes will have the greatest opportunity through quality improvement to save the most lives.
SPECIAL SECTION: RESUSCITATION RECOMMENDATIONS
- In-Depth Summary of 2015 AHA Guidelines Updates for EMS Providers
- Prehospital Naloxone Administration for Opioid-Related Emergencies
- Prehospital Targeted Temperature Management in Cardiac Arrest Patients
- Why We Should No Longer Terminate Resuscitations after 20 Minutes
- Revising Your Protocols to Comply with the 2015 AHA Guidelines