In 2005, considerable scientific work was invested in revising the American Heart Association’s (AHA) Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC).(1) Over the past five years, these Guidelines have shaped the training of millions of people and likely resulted in many lives saved.(2) Two key changes in the 2005 Guidelines were the recommendation to focus on delivery of high-quality chest compressions and to switch to a one-shock protocol. Studies suggest that these two changes alone have had a dramatic impact on the effectiveness of CPR.(3, 4)
Expectations are high, then, for the recently published 2010 revision to the AHA’s CPR and ECC Guidelines,(5) especially because the new Guidelines coincide with the 50th anniversary of CPR.
The most striking change in 2010 is a revision to the 50-year-old single-rescuer CPR sequence: “ABC” becomes “CAB.” Prioritizing compressions over ventilations is an extension of the 2005 focus on delivering high-quality chest compressions, further cementing compressions as the foundation of resuscitation.
This major change, as well as all changes considered by the authors of this supplement to be most relevant to EMS, are highlighted in the following pages. Perhaps as important, though, is the shift in the philosophy underlying the 2010 Guidelines. The new Guidelines recognize the real-life challenge of consistently and optimally applying each vital link in the chain of survival. The intention is that every community will implement cardiac arrest/resuscitation education, tracking and evaluation strategies in an integrated system to save even more lives.
EMS plays a primary role in such integrated systems, providing the initial definitive care to victims of cardiovascular emergencies and promoting CPR training in the community. More importantly, EMS is the key to building an effective integrated system by firmly linking the bystander who initiates CPR (and, sometimes, provides defibrillation) with the hospital, where the road to neurologically intact recovery is supported by specialized post-resuscitation care.
For that reason, we have created this supplement to focus on what the 2010 AHA Guidelines for CPR and ECC mean to you, the EMS professional.
Note: The following information is excerpted/adapted from the 2010 Guidelines with permission from the American Heart Association.
Basic Life Support (Guidelines Parts 4, 5 & 7)
Recognition/Assessment
“¢ When encountering an unconscious person, briefly check for no breathing or no normal breathing (i.e., no breathing or only gasping) at the same time as checking responsiveness.
“¢ You no longer need to “look, listen and feel for breathing.”
“¢ Recognize unresponsiveness and absence of normal breathing (e.g., apnea, gasping) as a sign of sudden cardiac arrest (SCA).
“¢ Treat unresponsive victims with occasional gasps as if they’re not breathing (Class I; see p. 8 for definitions).
“¢ To minimize delays in starting compressions, start compressions if you don’t feel a pulse within 10 seconds (Class IIa).
Sequence & Chest Compressions
“¢ Agencies and EMS personnel should strive for a simultaneous, choreographed approach to compressions, airway management, rescue breathing, rhythm detection and shocks by an integrated team of highly trained rescuers.
“¢ Initiate chest compressions before giving rescue breaths (CAB rather than ABC). Beginning CPR with compressions rather than ventilations leads to a shorter delay to first compression (Class IIb).
“¢ A compression-ventilation ratio of 30:2 is recommended. Once an advanced airway is placed, continuous compressions should be delivered without pauses for ventilation (Class IIa).
“¢ Use a compression rate of at least 100/min. (previously stated as “approximately” 100/min.). Improved survival has occurred with compression rates as high as 120/min.
“¢ A compression depth for adults of at least 2 inches (or 5 cm) is recommended (this is deeper than the previously recommended minimum).
“¢ Allow the chest to completely recoil after each compression (Class IIa).
“¢ Rescuers may use real-time CPR prompting and feedback technology to improve CPR quality.
“¢ The frequency and duration of interruptions in compressions should be minimized to maximize the number of compressions per minute (Class IIa).
“¢ When two or more rescuers are present, switch chest compressors approximately every two minutes to prevent decreases in the quality of compressions (Class IIa).
“¢ ECG rhythm should be checked after every two minutes of chest compressions. The pulse should be checked only when an organized rhythm is seen.
Ventilation
“¢ Trained rescuers should use conventional CPR with rescue breathing because rescue breathing is an important component for successful resuscitation from asphyxial, pediatric and prolonged cardiac arrests (Class IIa).
> Once compressions have started, deliver breaths by mouth-to-mouth or bag-valve mask (when more than one rescuer is present) to provide oxygenation and ventilation. Compression-ventilation ratios remain unchanged from 2005, and volumes should be sufficient to make the chest rise.
“¢ Avoid excessive ventilation (too many breaths or too large a volume) during CPR (Class III). Note:
> Normal ventilation-perfusion relationships can be maintained with minute ventilation lower than normal because blood flow is reduced during CPR.
> Excessive ventilation is unnecessary and can:
- cause gastric inflation, which can result in regurgitation and aspiration;
- elevate the diaphragm, restrict lung movement and decrease respiratory system compliance; and
- increase intrathoracic pressure, decrease venous return to the heart, and diminish cardiac output and survival.
“¢ Perform airway maneuvers quickly and efficiently to minimize interruptions in compressions and do not delay compressions when setting up an airway device.
“¢ Bag-valve mask ventilation is not the recommended method of ventilation for a lone rescuer during CPR. When CPR is performed by a lone rescuer, mouth-to-mouth or mouth-to-mask ventilation is more efficient.
“¢ Routine use of cricoid pressure during ventilations in cardiac arrest is generally not recommended because it may impede ventilation and interfere with placement of an advanced airway.
“¢ During cardiac arrest, pulse oximetry typically does not produce a reliable signal because pulsatile blood flow is inadequate in peripheral tissue beds. Pulse oximetry is useful to ensure appropriate oxygenation after ROSC.
CPR Techniques
“¢ Continue to provide chest compressions at a frequency of at least 100/min., and minimize interruptions. There is not sufficient evidence to recommend high-frequency chest compressions at greater than 120/min.
“¢ BLS providers should not use a precordial thump, because it is considered ineffective and may result in serious complications.
Devices to Assist Ventilation and/or Circulation
“¢ Oropharyngeal airways (OPAs) can facilitate delivery of ventilation with a bag-mask device. They can be used by appropriately trained providers for unconscious patients or for unresponsive patients with no cough/gag reflex (Class IIa).
“¢ Nasopharyngeal airways (NPAs) are useful when clenched jaw prevents use of an OPA. NPAs are better tolerated than OPAs by patients not deeply unconscious. Note: For patients with known or suspected basilar skull fracture or severe coagulopathy, OPA is preferred.
“¢ There’s insufficient evidence to support or refute the routine use of mechanical devices to deliver chest compressions during cardiac
arrest, however:
> Mechanical piston chest-compression devices may be considered for use by properly trained personnel in specific settings or circumstances that make manual resuscitation difficult (Class IIb, Level of Evidence [LOE] C);
> Load-distributing band chest-compression devices may be considered for use by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb, LOE B); and
> Active compression-decompression CPR (ACD-CPR) may be considered for use when providers are adequately trained and monitored (Class IIb, LOE B).
“¢ There’s insufficient evidence to support or refute the use of phased thoracic-abdominal compression-decompression CPR (PTACD-CPR) for the treatment of cardiac arrest.
“¢ For trained providers, the impedance threshold device (ITD) may be considered as a CPR adjunct in adult cardiac arrest (Class IIb, LOE B).
Electrical Therapies (Guidelines Parts 5 & 6)
“¢ For adult out-of-hospital cardiac arrest, there’s insufficient evidence to recommend for or against delaying defibrillation to provide a period of CPR for patients in ventricular fibrillation or pulseless ventricular tachycardia.
“¢ Continue chest compressions while the AED is charging; stop compressions just prior to delivery of the shock. Immediately resume chest compressions after the shock.
“¢ When an AED is capable of delivering an escalating dose of biphasic energy for defibrillation, higher energy levels may be considered, if available, for second and subsequent shocks. The maximum adult defibrillation energy dose is unchanged at 360 J.
“¢ Pacing is not routinely recommended for patients in asystolic cardiac arrest.
Pediatric Defibrillation
“¢ Use an initial dose of 2—4 J/kg for defibrillation on infants and children (when using a monophasic or biphasic manual defibrillator). The subsequent doses are 4 J/kg.
“¢ Anterior-lateral pad position is a reasonable default electrode placement. Any of three alternative pad positions (anterior-posterior, anterior-left infrascapular, and anterior-right infrascapular) may be considered, based on individual patient characteristics.
ACLS (Guidelines Parts 7 & 8)
Cardiac Arrest
“¢ One algorithm for all cardiac arrest patients still exists; however, that algorithm is now simplified and presented in two versions: the linear algorithm similar in form to previous versions (Figure 1) and a new, circular algorithm that emphasizes the cyclical nature of action and reassessment (Figure 2). Both versions underscore the principles of transforming conventional CPR into high-quality CPR.
“¢ The precordial thump should not be used for unwitnessed out-of-hospital cardiac arrest (Class III, LOE C). The precordial thump may be considered for patients with witnessed, monitored, unstable ventricular tachycardia, including pulseless VT, if a defibrillator is not immediately ready for use (Class IIb, LOE C), but it should not delay CPR and shock delivery. There’s insufficient evidence to recommend for or against the use of the precordial thump for witnessed onset of asystole.
“¢ Perform CPR while the defibrillator is readied for use (Class I).
“¢ Delaying the first shock in order to provide a period of CPR is acceptable, but the benefit is unclear for patients found in cardiac arrest (Class IIb).
“¢ At this time, there’s insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers.
“¢ Rescuers should not routinely use cricoid pressure during cardiac arrest (Class III).
Advanced Airway
“¢ If advanced airway placement interrupts chest compressions, rescuers may delay insertion until the patient achieves ROSC or fails to respond to initial resuscitation attempts (Class IIb).
“¢ During CPR performed by trained providers, the supraglottic airway is a reasonable alternative to bag-mask ventilation (Class IIa) and endotracheal intubation (Class IIa).
Waveform Capnography
“¢ Continuous waveform capnography, in addition to clinical assessment, is the most reliable method of confirming and monitoring correct placement of an endotracheal tube (Class I) and is preferred to other techniques.
“¢ When waveform capnography is not available, use an esophageal detection device (EDD), colorimetric or nonwaveform PetCO2 detectors, in addition to clinical assessment, as the initial methods for confirming correct tube placement (Class IIa).
“¢ Capnography provides a reasonable strategy to measure and optimize the effectiveness of chest compressions during cardiac arrest and assess ROSC (Class IIb).
New Medication Recommendation:
Atropine
“¢ Atropine is unlikely to have a therapeutic benefit for patients suffering from pulseless electrical activity (PEA) or asystole and is no longer recommended for routine use during cardiac arrest (Class IIb).
New Medication Administration:
Adenosine
“¢ Intravenous adenosine remains the recommended initial drug therapy for stable narrow-complex tachycardia (Class I; no change from 2005).
“¢ Rescuers may administer adenosine to any stable, regular and undifferentiated wide-complex tachycardia (Class IIb).
“¢ Rescuers should not administer adenosine to patients with irregular wide-complex tachycardia (Class III).
Symptomatic Bradycardia
(see Figure 7 on p. 30)
“¢ Although bradycardia in an adult is defined as <60 bpm, the rate is generally <50 bpm when bradycardia is the cause of symptoms.
“¢ If available, a 12-lead ECG should be used to better define the rhythm–as long as it can be performed without significantly delaying therapy.
“¢ Atropine remains the first-line therapy for acute, symptomatic bradycardia.
“¢ Transcutaneous pacing (TCP) may be initiated in unstable patients who do not respond to atropine (Class IIa). Immediate TCP might be considered in unstable patients with high-degree heart block when IV access is not available (Class IIb).
“¢ Dopamine and epinephrine infusion may be used for patients with symptomatic bradycardia, particularly if associated with hypotension, in whom atropine may be inappropriate or after atropine fails (Class IIb).
Symptomatic Tachycardia
(see Figure 8 on p. 33)
“¢ When the heart rate is <150, it’s unlikely that symptoms of instability are caused primarily by the tachycardia unless there’s impaired ventricular function.
“¢ ACLS professionals should be able to recognize and differentiate between three general categories of tachycardia: sinus tachycardia, supraventricular tachycardia (SVT) and ventricular tachycardia (VT). Most wide-complex tachycardias (QRS >0.12 second) are ventricular in origin.
“¢ Use the following three-step approach for patients with wide-complex tachycardia:
1. Determine if the patient is stable or unstable (if unstable, presume VT and perform immediate cardioversion);
2. If the patient is stable, perform a 12-lead ECG to evaluate the rhythm and determine if QRS complex duration is >0.12 second; and
3. Determine if the rhythm is regular or irregular.
> Wide and regular: likely VT or SVT with aberrancy.
> Wide and irregular: atrial fib with aberrancy or polymorphic VT.
“¢ Synchronize cardioversion energy (increase energy dose in a stepwise fashion for repeat shocks, if initial attempt fails):
> Narrow regular (SVT, atrial flutter): initial 50—100 J.
> Narrow irregular (atrial fibrillation): initial 120—200 J or 200 J monophasic.
> Wide regular (VT monomorphic): initial 100 J.
> Wide irregular: defibrillation dose (polymorphic VT will usually not permit synchronization; deliver unsynchronized shocks).
Post-Cardiac Arrest Care (Guidelines Part 9)
EMS Providers–BLS and ALS
“¢ Avoid hyperventilation (i.e., “overbagging”) in patients resuscitated from out-of-hospital cardiac arrest (OHCA) to avoid potential adverse hemodynamic effects (e.g., lowering patient’s cardiac output and, consequently, cerebral perfusion).
“¢ Although it’s common to provide 100% oxygen during the initial process of resuscitation, prehospital personnel should maintain oxygen saturation of >94% with the lowest required FiO2 after the patient achieves ROSC.
“¢ Monitor patient closely because re-arrest is common during early ROSC.
“¢ Transport to appropriate hospital with comprehensive post-cardiac arrest treatment system of care that includes acute coronary intervention, neurologic care, goal-directed critical care and hypothermia.
EMS Providers–additional information for ALS
“¢ Ensure adequate placement of an advanced airway for unconscious patients who achieve ROSC and use waveform capnography for continuous monitoring during transport.
“¢ Optimize ventilation (10—12 breaths/min.; titrate to PetCO2 of 35—40 mmHg).
“¢ Hemodynamic instability is common after cardiac arrest. Optimize cardiovascular perfusion, treat hypotension (<90 mmHg systolic) with IV fluid boluses as needed and consider initiating vasopressors, such as dopamine, norepinephrine or epinephrine, if necessary, to sustain a systolic blood pressure of >90 mmHg or a mean arterial pressure of >65 mmHg.
“¢ Identify and start treatment for potential reversible causes (five Hs: hypovolemia, hypoxia, hydrogen ion [acidosis], hyper/hypokalemia, hypothermia and the five Ts: toxins [drug overdose], tamponade-cardiac, tension pneumothorax, thrombosis-coronary, thrombosis-pulmonary).
“¢ Obtain a 12-lead ECG as soon as possible for all ROSC patients to detect ST segment elevation myocardial infarction (STEMI) or new left bundle branch block (LBBB), and activate local reperfusion protocols accordingly.
“¢ Do not actively rewarm comatose patients who spontaneously develop mild hypothermia
(>32° C [89.6° F]) after OHCA (Class III, LOE C).
“¢ Consider the titrated use of sedation and analgesia in post-cardiac arrest patients who require mechanical ventilation or shivering suppression during induced hypothermia (Class IIb, LOE C).
EMS System Administrators/Medical Directors
“¢ Resuscitation should generally be conducted where the patient is found (Class IIa) because of the difficulty in providing effective chest compressions while moving the patient.
“¢ Develop comprehensive, community system-of-care processes for the treatment of post-cardiac arrest patients (Class I, LOE B).
“¢ Develop appropriate triage destination policies for post-cardiac arrest care patients depending on local community resources.
“¢ Educate and train prehospital providers in the early management of post-cardiac arrest patients.
“¢ Termination of resuscitation in the field, using established criteria, reduces unnecessary transport to the hospital, reducing associated road hazards that put the provider, patient and public at risk. In addition, field termination reduces inadvertent exposure to potential biohazards and the higher cost of ED pronouncement. Most importantly, the quality of CPR is compromised during transport, and survival is linked to optimizing scene care rather than rushing to the hospital.
Acute Coronary Syndrome (ACS) (Guidelines Part 10)
“¢ Routinely acquire a 12-lead ECG as soon as possible for all patients exhibiting signs and symptoms suggestive of acute coronary syndrome (ACS)–chest discomfort, discomfort in upper body areas, dyspnea/SOB, sweating/diaphoresis, nausea, vomiting and dizziness. Atypical symptoms are more common in women, the elderly and diabetic patients.
“¢ If providers aren’t trained to interpret the 12-lead ECG, field transmission of ECG or computer report to receiving hospital is recommended (Class I).
“¢ Implementation of 12-lead ECG diagnostic programs with concurrent medically directed quality assurance is recommended (Class I).
“¢ Provide advance notification to the receiving hospital for patients identified as having STEMI.
“¢ There’s insufficient evidence to support the routine use of oxygen in patients with an uncomplicated ACS. If the patient is dyspneic or hypoxemic or has obvious signs of heart failure, providers should titrate oxygen therapy to achieve an oxygen saturation of >94%.
“¢ Use morphine in STEMI when chest discomfort is unresponsive to nitrates, but use it with caution in unstable angina due to an association with increased mortality in a large registry.
“¢ For patients with ACS, there’s no evidence to support the 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.
“¢ Continuous ECG monitoring is important because the incidence of primary VF is highest in the first four hours after symptom onset, and is an important contributor to mortality in the first 24 hours.
“¢ Prophylactic antiarrhythmics are not recommended for patients with ACS or MI prehospital or ED (class III).
Adult Stroke (Guidelines Part 11)
Contributors’ note: The 2010 Adult Acute Ischemic Stroke update does not focus on a specific “new treatment,” but rather reinforces the importance of developing stroke systems of care to most effectively deliver proven therapies for acute ischemic stroke.
EMS Administrators
“¢ Triage to appropriate stroke hospitals plays an increasingly important role. With three levels of stroke-capable hospitals (see below) now available to patients, EMS agencies must know where the nearest appropriate stroke hospital is located and the stroke hospital’s capabilities.
“¢ Three levels of hospital stroke capability are now used to define stroke-capable hospitals:
> Stroke-Prepared Hospitals utilize telemedicine to provide on-site stroke expertise, allowing for fibrinolytic therapy consideration.
> Primary Stroke Centers (PSC), as defined by the Brain Attack Coalition and now certified by the Joint Commission and many states, provide emergent assessment, fibrinolytic therapy and admission to Stroke Units.
> Comprehensive Stroke Centers (CSC) expand on PSC capabilities by providing advanced neuroimaging techniques, intra-arterial approaches to recanalization, neurosurgical expertise and advanced neurointensive care.
“¢ CSCs can provide access to advanced diagnostic imaging and treatments beyond those required for IV fibrinolytic therapy and should be preferentially used for patients with stroke onset beyond three hours or with unknown onset times, larger strokes, or obvious contraindications to fibrinolytic therapy.
“¢ Telemedicine provides access to remote stroke expertise, allowing traditionally smaller, more rural hospitals to provide emergent stroke assessment and treatment.
Special Situations (Guidelines Parts 5 & 12)
Contributors’ note: The seven special situations listed below are selected from 15 included in the 2010 Guidelines due to their relevance for the EMS community. Only the most significant changes or clarifications are listed for each.
Asthma
“¢ During manual ventilation, a slower respiratory rate (6—12/min) should be used with smaller tidal volumes (6—8 mL/kg), shorter inspiratory time, and longer expiratory time (inspiratory to expiratory ratio of 1:4 or 1:5).
“¢ Because the effects of auto-PEEP in an asthmatic patient with cardiac arrest are likely quite severe, a ventilation strategy of low respiratory rate and tidal volume is reasonable (Class IIa, LOE C).
“¢ During cardiac arrest, a brief disconnection from the bag mask or ventilator may be considered, and compression of the chest wall to relieve air-trapping can be effective (Class IIa, LOE C). This may also be performed if auto-PEEP results in hypotension.
“¢ For all asthmatic patients with cardiac arrest, and especially for patients in whom ventilation is difficult, the possible diagnosis of a tension pneumothorax should be considered and treated (Class I, LOE C).
Anaphylaxis
“¢ Alternative vasoactive drugs (e.g., vasopressin, norepinephrine, methoxamine and metaraminol) may be considered in cardiac arrest secondary to anaphylaxis that does not respond to epinephrine (Class IIb, LOE C).
Pregnancy
“¢ Additional intervention for preventing arrest: Maternal hypotension that warrants therapy has been defined as a systolic BP <100 mmHg or <80% of baseline. In the patient who is not in arrest, both crystalloid and colloid solutions have been shown to increase preload.
“¢ To relieve aortocaval compression during chest compression and optimize the quality of CPR, it’s reasonable to perform manual left uterine displacement in the supine position first (Class IIa). If this is unsuccessful and a wedge is available, providers may consider placing the patient in a left-lateral tilt of 27—30o, using a firm wedge to support the pelvis and thorax (Class IIb).
“¢ Additional details are also provided regarding airway management, ventilation volumes and the importance of mask ventilation with 100% oxygen before intubation is attempted.
Morbid Obesity
“¢ No difference in survival based on patient weight has been demonstrated among adult patients, but there is some evidence of a lower survival rate among morbidly obese children who required in-hospital resuscitation.
“¢ No modifications to standard BLS or ACLS care have been proven efficacious, although techniques may need to be adjusted due to the physical attributes of individual patients.
Toxic Substances
“¢ Patients in cardiac arrest or those presenting with cardiovascular instability caused by known or suspected cyanide poisoning (e.g., smoke inhalation) should receive a treatment regimen of 100% oxygen and hydroxocobalamin, with or without sodium thiosulfate (Class I).
Accidental Hypothermia
“¢ When VT or VF persists after a single shock, the value of deferring subsequent defibrillations until a target temperature is achieved is uncertain. It may be reasonable to perform further defibrillation attempts according to the standard BLS algorithm concurrent with rewarming strategies.
“¢ It may be reasonable to consider administration of a vasopressor during cardiac arrest according to the standard ACLS algorithm concurrent with rewarming strategies.
Drowning
“¢ All victims of drowning who require any form of resuscitation (including rescue breathing alone) should be transported to the hospital for evaluation and monitoring, even if they appear to be alert and demonstrate effective cardiorespiratory function at the scene (Class I).
“¢ Routine stabilization of the cervical spine in the absence of circumstances that suggest a spine injury is not recommended (Class III) because the incidence of cervical spine injury in drowning victims is low and cervical spine immobilization can impede adequate airway opening and delay delivery of rescue breaths.
“¢ Because of the advent of hands-only (compressions-only) CPR and the emphasis on chest compressions for unresponsive and non-breathing victims, providers are reminded that drowning victims are asphyxia victims and, thus, they need early ventilation and oxygenation.
Pediatrics (Guidelines Parts 13, 14)
Pediatric BLS
“¢ If there’s a palpable pulse >60, but the patient shows inadequate breathing, give rescue breaths at a rate of 12—20 breaths/minute (one breath every three to five seconds) using the higher rate for younger children (Class I).
“¢ If the pulse is <60 and there are signs of poor perfusion (pallor, mottling, cyanosis) despite support of oxygenation and ventilation, begin chest compressions. Beginning CPR prior to full cardiac arrest results in improved survival.
“¢ Place less emphasis on the pulse check. For an unresponsive and non-breathing child, begin CPR if a pulse cannot be detected within 10 seconds (Class IIa).
“¢ Initiate CPR with chest compressions rather than rescue breaths (CAB rather than ABC). Asphyxial cardiac arrest is more common in infants and children, and ventilations are extremely important in pediatric resuscitation. The CAB sequence for infants and children is to simplify training. Therefore, start CPR with chest compressions immediately, while a second rescuer prepares to provide ventilation (Class I).
“¢ Compress at a rate of at least 100/min. After each compression, allow the chest to recoil completely (Class IIb).
“¢ Depth of compressions is at least one-third (1/3) the anterior-posterior diameter of the chest or approximately 1½ inches (4 cm) in infants and 2 inches (5 cm) in children (Class I). Note: Inadequate compression depth and incomplete recoil is common even among trained providers.
“¢ For the lone rescuer, a compression-ventilation ratio of 30:2 is recommended. For two rescuers, a ratio of 15:2 is recommended.
“¢ Oropharyngeal and nasopharyngeal airways help maintain an open airway. Make sure to select the correct size.
“¢ Deliver ventilations with as short a pause in compressions as possible (Class IIa). If an advanced airway is in place, compressions should be delivered without pauses for ventilation. Ventilations should be delivered at a rate of eight to 10 breaths/minute (every six to seven seconds) without interrupting compressions. Avoid excessive ventilation (Class III).
Pediatric Defibrillation
“¢ Follow package directions for placement of defibrillator pads. Place manual electrodes over the right side of upper chest and the apex of the heart (to left of nipple over left lower ribs). There is no advantage in an anterior-posterior position of the paddles.
“¢ Paddle size: Use the largest electrodes that will fit on the child’s chest without touching, leaving about 3 cm between electrodes. “Adult” size (8—10 cm) electrodes should be used for children >10 kg (approximately one year). “Infant” size should be used for infants <10 kg.
“¢ An initial dose of 2 to 4 J/kg is acceptable (Class IIa). For refractory VF, it’s reasonable to increase the dose to 4 J/kg (Class IIa). Higher energy levels may be considered, not to exceed 10 J/kg or the adult maximum dose (Class IIb).
“¢ If an AED with an attenuator is not available, use an AED with standard electrodes (Class IIa).
“¢ In infants <1 year, a manual defibrillator is preferred. If not available, an AED with an attenuator may be used. An AED without a dose attenuator may be used if neither a manual defibrillator nor a dose attenuator is available (Class IIb).
Pediatric ALS
“¢ The PALS cardiac arrest algorithm is simplified and organized around two-minute periods of uninterrupted CPR.
“¢ Exhaled CO2 detection is recommended as confirmation of tracheal tube position with a perfusing rhythm in all settings (Class I) and during intra- or inter-hospital transport (Class IIb). Capnography/capnometry, used for confirming proper endotracheal tube position, may also be useful to assess and optimize the quality of chest compressions during CPR (Class IIa). It may also spare the rescuer from interrupting chest compressions for a pulse check because an abrupt and sustained rise in PetCO2 is observed just prior to clinical identification of ROSC.
“¢ Upon ROSC, titrate inspired oxygen (when oximetry is available) to maintain an arterial oxyhemoglobin saturation >94% but <100% to limit the risk of hyperoxemia.
“¢ Bradycardia with pulse and poor perfusion: epinephrine (Class I), atropine (Class I) and pacing (Class IIb) may be used.
“¢ Tachycardia with pulse and poor perfusion:
> Narrow complex (QRS <0.09) SVT: Attempt vagal stimulation. Adenosine is the drug of choice (Class I).
- If hemodynamically unstable or adenosine are ineffective, perform synch cardioversion, starting at a dose of 0.5 to 1 J/kg, increasing to 2 J/kg (Class IIb).
> Wide complex (QRS>0.09) tachycardia, hemodynamically stable: Adenosine may be considered if the rhythm is regular and monomorphic and is useful to differentiate SVT from VT. Consider cardioversion using energy described for SVT. Expert consultation is strongly recommended prior to administration of amiodarone or procainamide.
- If hemodynamically unstable, cardioversion is recommended (Class I).
“¢ Routine calcium administration is not recommended for pediatric cardiopulmonary arrest in the absence of documented hypocalcemia, calcium channel blocker overdose, hypermagnesemia or hyperkalemia.
“¢ Etomidate has been shown to facilitate endotracheal intubation in infants and children with minimal hemodynamic effect but is not recommended for routine use in pediatric patients with evidence of septic shock.
“¢ Although there have been no published results of prospective randomized pediatric trials of therapeutic hypothermia, based on adult evidence, therapeutic hypothermia (to 32—34°C) may be beneficial for adolescents who remain comatose after resuscitation from sudden, witnessed, out-of-hospital VF cardiac arrest. Therapeutic hypothermia (to 32—34°C) may also be considered for infants and children who remain comatose after resuscitation from cardiac arrest.
“¢ Whenever possible, provide family members with the option of being present during resuscitation of an infant or child (Class I).
Neonates
“¢ Very low birthweight preterm babies are likely to become hypothermic despite the use of traditional techniques for decreasing heat loss. Additional warming techniques are recommended (e.g., prewarming room, covering baby in plastic wrapping [food/medical grade, heat resistant plastic]) (Class I).
“¢ The recommended compression-to-ventilation ratio remains 3:1. If the arrest is known to be of cardiac etiology, consider a higher ratio (15:2).
“¢ Once positive-pressure ventilation or supplementary oxygen administration is begun, assessment of the neonate’s condition should include heart rate, respiratory rate and evaluation of the state of oxygenation, preferably using pulse oximetry.
“¢ For resuscitation of babies born at term, begin with air rather than 100% oxygen. Administration of supplemental oxygen should be guided by oximetry.
“¢ Suctioning immediately after birth (including suctioning with a bulb syringe) should be reserved for babies who have an obvious obstruction to spontaneous breathing or require positive-pressure ventilation.
“¢ Positive-pressure ventilation should be administered with sufficient pressure to increase the heart rate or create chest expansion; excessive pressure can seriously injure the preterm lung.
“¢ Exhaled CO2 detectors are recommended to confirm endotracheal intubation, although there are rare false negatives in the face of inadequate cardiac output and false positives with contamination of the detectors.
“¢ There’s increasing evidence of benefit of delaying cord clamping for at least one minute in term and preterm infants not requiring resuscitation. There’s insufficient evidence to support or refute a recommendation to delay cord clamping in babies requiring resuscitation.
Emergency Medical Dispatchers (Guidelines Part 5)
“¢ Dispatchers should be appropriately trained to provide telephone CPR instructions. Specifically, dispatchers should:
> Immediately ask straightforward questions to determine if patient is conscious and breathing normally to identify patients with possible cardiac arrest.
> Be specifically educated in recognition of abnormal breathing to improve recognition of gasping and cardiac arrest (Class I).
> Recommend CPR for unresponsive victims who are not breathing normally because most are in cardiac arrest and the frequency of serious injury from compressions in persons not in arrest is very low (Class I).
> Instruct untrained lay rescuers to provide hands-only CPR for adults with sudden cardiac arrest (Class I).
> Include rescue breathing in their telephone CPR instructions for treating victims with a high likelihood of asphyxial cause of arrest (e.g., children or drowning victims).
“¢ To improve ACS outcome, all dispatchers and EMS providers must be trained to recognize ACS symptoms, even if atypical. It is reasonable for dispatchers to advise patients with potential cardiac symptoms to chew an aspirin (160—325 mg), providing the patient has no history of aspirin allergy and no signs of active or recent gastrointestinal bleeding (Class IIa, LOE C).
Lay Providers (Guidelines Parts 4, 5 & 17)
“¢ Untrained bystanders should provide hands-only (compressions-only) CPR for the adult victim who suddenly collapses.
“¢ Trained lay rescuers should provide chest compressions for victims of cardiac arrest. If the trained lay rescuer is able to perform rescue breaths, compressions and breaths should be provided in a ratio of 30 compressions to two breaths.
“¢ Chest compressions should be initiated before ventilations: “CAB” instead of “ABC.”
“¢ Chest compression rate is now at least 100/min. (previously stated as “approximately 100/min.”).
“¢ Chest compression depth (for adult victims) is now at least 2 inches (5 cm) (previously stated recommended range was “about 1½ to 2 inches [or 4 to 5 cm]”).
“¢ Routine administration of supplementary oxygen is not recommended as a first aid measure for shortness of breath or chest discomfort but supplementary oxygen administration should be considered as part of first aid for divers with a decompression injury.
“¢ Activate the EMS system for anyone with chest discomfort. While waiting for EMS to arrive, advise the patient to chew one adult (non—
enteric-coated) or two low-dose “baby” aspirin if the patient has no history of allergy to aspirin and no recent gastrointestinal bleeding.
Education, Implementation & Teams
“¢ The current two-year certification period for BLS and ALS courses should include periodic assessment of rescuer knowledge and skills, with reinforcement or refresher information provided as needed.
“¢ BLS skills can be learned equally well with practice while watching a video presentation as with longer, traditional, instructor-led courses.
“¢ Training in teamwork and leadership skills should continue to be included in ACLS and PALS courses.
“¢ Manikins with realistic features, such as the capability to demonstrate chest expansion and breath sounds, generate a pulse and blood pressure, and speak, may be useful for integrating the knowledge, skills and behaviors required in ACLS and PALS training. Written tests shouldn’t be used exclusively to assess the competence of a participant in an ACLS or PALS course; performance assessment is also needed.
“¢ Formal assessment should continue to be included in resuscitation courses as a method of evaluating both the success of the student in achieving the learning objectives and the effectiveness of the course.
“¢ CPR prompt and feedback devices may be useful for training rescuers.
“¢ Debriefing is a learner-focused, nonthreatening technique to help individual rescuers and teams reflect on and improve performance.
Debriefing should be included in ALS courses to facilitate learning and can be used to review and improve performance in the clinical setting.
“¢ Improving care requires assessment of performance. Systematically monitor cardiac arrests, the level of resuscitation care provided and outcomes. The cycle of measurement, interpretation, feedback and continuous quality improvement provides fundamental information necessary to optimize resuscitation care and should help narrow the knowledge and clinical gaps between ideal and actual resuscitation performance.
“¢ Evidence supports the importance of accurately identifying each instance of treated cardiac arrest and measuring outcomes and suggests additional opportunities for improving survival rates in many communities.
“¢ The process of simply measuring and benchmarking care can positively influence outcome. However, ongoing review and interpretation are necessary to identify areas for improvement.
References
1. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2005;112(24 Suppl):IV1—203.
2. Hinchey PR, Myers JB, Lewis R, et al. Improved out-of-hospital cardiac arrest survival after the sequential implementation of 2005 AHA guidelines for compressions, ventilations, and induced hypothermia: The Wake County experience. Ann Emerg Med.2010;56(4):348—357.
3. Rea TD, Shah S, Kudenchuk PJ, et al. Automated external defibrillators: To what extent does the algorithm delay CPR? Ann Emerg Med. 2005;46(2):132—141.
4. 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.
5. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(suppl 3):S640—S946.
This article originally appeared in the January 2011 JEMS supplement "Evolution in Resuscitation" as "What's New & Why: A summary of changes in the 2010 AHA CPR Guidelines"
