Cardiopulmonary Resuscitation is an emergency life saving procedure consisting of delivering effective chest compressions and effective ventilations to a victim of cardiac arrest. The American Society of Anesthesiology and European Resuscitation Council have made evidence based guidelines for the efficient and proper conduct of high quality CPR.These guidelines, being revised from time to time according to newer evidences, research and outcome help the primary care provider to offer the best care for the victims of cardiac arrest.The 2010 AHA Guidelines for CPR and ECC are based on an international evidence evaluation process that involved hundreds of international resuscitation scientists and experts who evaluated, discussed, and debated thousands of peer reviewed publications. Here is the new" guidelines(2010) in nutshell' for CPR from AHA .The major changes have been highlighted.A detailed information of both ERC and AHA Guidelines, is available from the resuscitation council links given below.
BASIC LIFE SUPPORT
1.Continued Emphasis on High-Quality CPR:
The 2010 AHA Guidelines for CPR and ECC once again emphasize the need for high-quality CPR, including
- A compression rate of at least 100/min (a change from“approximately” 100/min)
- A compression depth of at least 2 inches (5 cm) in adults and a compression depth of at least one third of the anteroposterior diameter of the chest in infants and children(approximately 1.5 inches [4 cm] in infants and 2 inches[5 cm] in children). Note that the range of 1½ to 2 inches is no longer used for adults, and the absolute depth specified for children and infants is deeper than in previous versions the AHA Guidelines for CPR and ECC
- Allowing for complete chest recoil after each compression
- Minimizing interruptions in chest compressions
- Avoiding excessive(hyper) ventilation
There has been no change in the recommendation for a compression-to-ventilation ratio of 30:2 for single rescuers of adults, children, and infants (excluding newly born infants). The 2010 AHA Guidelines for CPR and ECC continue to recommend that rescue breaths be given in approximately 1 second. Once
an advanced airway is in place,rescue breaths can be provided at about 1 breath every 6 to 8 seconds (about 8 to 10 breaths/minute) and need not be synchronised with chest compressions which can be
continuous (at a rate of at least 100/min)
2.A Change From A-B-C to C-A-B
The major change made in BLS, from airway, breathing,and circulation the sequence has been changed to compression,airway and breathing .This is to aviod delay in delivering fast and effective chest compressions. Securing airway as the initial priority is time consuming and may not be 100% successful, especially by lone rescuers or paramedics.The vast majority of cardiac arrests occur in adults and the commonest causes for arrest are VF or pulseless VT. A witnessed cardiac arrest in these cases can be efficiently reverted with immediate defibrillation and cardiac compressions, which is life saving, and should be the goal in BLS.. In the A-B-C sequence, chest compressions are often delayed while the responder opens the airway to give mouth-to-mouth breaths, retrieves a barrier device,or gathers and assembles ventilation equipment.After initiating the emergency response system the next important thing is to start chest compressions.Only infant cpr is an exception to this protocol,where the previous sequence remains unchanged. That means no more looking, listening and feeling,as this component of assessment is removed from the guidelines. In the C-A-B sequence,chest compressions will be initiated sooner and ventilation only minimally delayed until completion of the first cycle of chest compressions. It was observed that the bystanders of the arrested victims do not actively participate in CPR as they find the first step of a-b-c sequence is difficult to perform. A-B-C starts with the most difficult procedures: opening the airway and delivering rescue breaths and that is the reason why less than one third of the victims in cardiac arrest receive by stander CPR in a witnessed cardiac arrest.. Hence a change in sequence to C-A-B
3.Compression rate: Should be at least 100/min (rather than“approximately” 100/min). The number of chest compressions delivered per minute during CPR is an important determinant of return of spontaneous circulation (ROSC) and survival with good neurologic function
4.Compression depth: For adults has been changed from the range of 1½ to 2 inches to at least 2 inches (5 cm).(The motto is push harder and faster) Effective compressions generate critical blood flow and oxygen and energy delivery to the heart and brain.
5.Hands Only CPR: Hands Only CPR. This is technically a change from the 2005 Guidelines, but AHA
endorsed this form of CPR in 2008. The Heart Association still wants untrained lay rescuers to do Hands Only CPR on adult victims who collapse in front of them.Hands-Only (compression-only) CPR is easier for an untrained rescuer to perform and can be more readily guided by dispatchers over the telephone.It was documented that survival rates from cardic arrest of cardiac origin are same irrespective of compressions alone(hands only cpr) or compressions with ventilations
5.Dispatcher Identification of Agonal Gasps: It is important that the rescuer shoul be well trained to identify between normal respirations from agonal breaths, in order to proceed with CPR. The lay rescuer should be taught to begin CPR if the victim is “not breathing or only gasping.” The healthcare provider should be taught to begin CPR if the victim has “no breathing or no normal breathing (ie, only gasping).”This rapid breathing check should be done before activation of emergency response system.
6.Cricoid Pressure: Routine use of cricoid pressure is not recommended as it may impede ventilation. Studies showed that cricoid pressure can delay or prevent the placement of an advanced airway and some aspiration can still occur even with proper application.In addition, it is difficult to appropriately train rescuers in use of this maneuver.
7.Activation of Emergency Response System: Should be made after assessment of the patients' responsiveness and breathing but should not be delayed. The 2005 guidelines states immediate activation of EMS after finding an unresponsive victim.(or send someone to do so), If the healthcare provider does not feel a pulse within 10 seconds, the provider should begin CPR and use the AED when it is available.
8. Concept of team resuscitation: For better and efficient delivery of resuscitation,is emphasized.
ELECTRICAL THERAPIES INCLUDING USE OF AED AND DEFIBRILLATOR.
1.AED Use in Children Now Includes InfantsFor attempted defibrillation of children 1 to 8 years of age with an AED, the rescuer should use a pediatric
dose-attenuator system if one is available. If the rescuer provides CPR to a child in cardiac arrest and does not have an AED with a pediatric dose-attenuator system, the rescuer should use a standard AED. For infants (<1 year of age), a manual defibrillator is preferred. If a manual defibrillator is not available,an AED with pediatric dose attenuation is desirable. If neither is available, an AED without a dose attenuator may be used. Automated external defibrillators with relatively high-energy doses have been used successfully in infants in cardiac arrest, with no clear adverse effects. No other major changes have bee made in electrical therapies including AED and defibrillator.
ADVANCED CARDIAC LIFE SUPPORT
1.Capnography Recommendation: Quantitative waveform capnography is recommended for confirmation of endotracheal tube placement and for monitoring CPR quality and detecting return of spontaneous circulation based on end tidal CO2. Because blood must circulate through the lungs for CO2 to be exhaled and measured, capnography can also serve as a physiologic monitor of the effectiveness of chest compressions and to detect return of spontaneous circulation. Ineffective chest compressions (due to either patient characteristics or rescuer performance) are associated with a low Petco2 and return of spontaneous circulation is associated with an abrupt increase in ETCO2. Previously an exhaled carbon dioxide (CO2) detector or an esophageal detector device was recommended to serve this purpose.
2.Simplified ACLS Algorithm and New Algorithm: The new circular algorithm is introduced in 2010
The conventional ACLS Cardiac Arrest Algorithm has been simplified and streamlined to emphasize
the importance of high-quality CPR. The 2010 AHA Guidelines for CPR and ECC note that CPR is ideally guided by physiologic monitoring and includes adequate oxygenation and early defibrillation while the ACLS provider assesses and treats possible underlying causes of the arrest. There is no definitive clinical evidence that early intubation or drug therapy improves neurologically intact survival to hospital discharge.The algorithm focusses on to the basics with an increased emphasis on what is known to work: high quality CPR.
3.New Medication Protocols:
- Atropine is not recommended for routine use in the management of PEA/asystole and has been removed from the ACLS Cardiac Arrest Algorithm.
- The algorithm for treatment of tachycardia with pulses has been simplified. Adenosine is recommended in the initial diagnosis and treatment of stable,undifferentiated regular, monomorphic wide-complex tachycardia (this is also consistent in ACLS and PALS recommendations). It is important to note that adenosine should not be used for irregular wide-complex tachycardias because it may cause degeneration of the rhythm to VF.
4.Organized Post–Cardiac Arrest Care: 2010 (New): Post–Cardiac Arrest Care is a new section
in the 2010 AHA Guidelines for CPR and ECC. To improve survival for victims of cardiac arrest who are admitted to a hospital after ROSC, a comprehensive, structured, integrated,multidisciplinary system of post–cardiac arrest care should be implemented in a consistent manner.Treatment should include cardiopulmonary and neurologic support. Therapeutic hypothermia and percutaneous coronary interventions (PCIs) should be provided when indicated.Because seizures are common after cardiac arrest, an electroencephalogram for the diagnosis of seizures should be performed with prompt interpretation as soon as possible and should be monitored frequently or continuously in comatose patients after ROSC.
5.Initial and Later Key Objectives of Post–Cardiac Arrest Care:
1. Optimize cardiopulmonary function and vital organ perfusion after ROSC
2. Transport/transfer to an appropriate hospital or critical care unit with a comprehensive post–cardiac arrest treatment system of care
3. Identify and treat ACS and other reversible causes
4. Control temperature to optimize neurologic recovery
5. Anticipate, treat, and prevent multiple organ dysfunction.This includes avoiding excessive ventilation and hyperoxia.
6.Tapering of Inspired Oxygen Concentration:
After ROSC Based on Monitored Oxyhemoglobin Saturation, ie, SPO2. New recommendation
The ethical issues relating to resuscitation are complex,occurring in different settings (in or out of the hospital) and among different providers (lay rescuers or healthcare personnel) and involving initiation or termination of basic and/or advanced life support. All healthcare providers should consider the ethical, legal, and cultural factors associated with providing care for individuals in need of resuscitation. Although providers play a
role in the decision-making process during resuscitation, they should be guided by science, the preferences of the individual or their surrogates, and local policy and legal requirements.
Terminating Resuscitative Efforts in Adults With Out-of-Hospital Cardiac Arrest
• Arrest not witnessed by EMS provider or first responder
• No ROSC after 3 complete rounds of CPR and AED analyses
• No AED shocks delivered
For situations when ACLS EMS personnel are present to provide care; for an adult with out-of-hospital cardiac arrest, an “ACLS termination of resuscitation” rule was established to consider
terminating resuscitative efforts before ambulance transport if all of the following criteria are met:
• Arrest not witnessed (by anyone)
• No bystander CPR provided
• No ROSC after complete ALS care in the field
• No shocks delivered
Implementation of these rules includes contacting online medical control when the criteria are met. In 2005 guidelines,no specific criteria were established
THE PEDIATRIC ADVANCED CARDIAC LIFE SUPPORT
Many key issues in the review of the PALS literature resulted in refinement of existing recommendations rather than new recommendations;
1. Monitoring capnography/capnometry is again recommended to confirm proper endotracheal tube position and may be useful during CPR to assess and optimize the quality of chest compressions.
2.The PALS cardiac arrest algorithm was simplified to emphasize organization of care around 2-minute periods of uninterrupted CPR.
3.The initial defibrillation energy dose of 2 to 4 J/kg of either monophasic or biphasic waveform is reasonable but for ease of teaching, a dose of 2 J/kg may be used (this dose is the same as in the 2005 recommendation). For second and subsequent doses, give at least 4 J/kg. Doses higher than 4 J/kg (not to exceed 10 J/kg or the adult dose) may also be safe and effective, especially if delivered with a biphasic defibrillator.
4.On the basis of increasing evidence of potential harm from high oxygen exposure, a new recommendation has been added to titrate inspired oxygen (when appropriate equipment is available), once spontaneous circulation has been restored, to maintain an arterial oxyhemoglobin saturation ≥94% but <100% to limit the risk of hyperoxemia.
5.New sections have been added on resuscitation of infants and children with congenital heart defects,including single ventricle, palliated single ventricle, and pulmonary hypertension. The use of extracorporial membrane oxygenation , if facilities are available is stressed.
6.Several recommendations for medications have been revised. These include, not administering calcium except in very specific circumstances like hypocalcemia, calcium channel blocker overdose,
hypermagnesemia, or hyperkalemia. and limiting the use of etomidate in septic shock. Routine calcium
administration in cardiac arrest provides no benefit and may be harmful.
7.Indications for postresuscitation therapeutic hypothermia have been clarified somewhat.(see below)
8.New diagnostic considerations have been developed for sudden cardiac death of unknown etiology.
9.Providers are advised to seek expert consultation, if possible, when administering amiodarone or procainamide to hemodynamically stable patients with arrhythmias.
10.The definition of wide-complex tachycardia has been changed from >0.08 second to >0.09 second.
When a sudden, unexplained cardiac death occurs in a child or young adult, obtain a complete past medical and family history (including a history of syncopal episodes, seizures, unexplained accidents/drowning, or sudden unexpected death at <50 years of age) and review previous ECGs. All infants, children, and young adults with sudden, unexpected death should, where resources allow, have an unrestricted complete autopsy,
preferably performed by a pathologist with training and experience in cardiovascular pathology. Tissue should be preserved for genetic analysis to determine the presence of channelopathy. It is explained as ;There is increasing evidence that some cases of sudden death in infants, children, and young adults may be associated with genetic mutations that cause cardiac ion transport defects known as channelopathies. These can cause fatal arrhythmias, and their correct diagnosis may be critically important for living relatives
1.Once positive-pressure ventilation or supplementary oxygen administration is begun, assessment should consist of simultaneous evaluation of 3 clinical characteristics:heart rate, respiratory rate, and evaluation of the state of oxygenation (optimally determined by pulse oximetry rather than assessment of color)
2. Anticipation of the need to resuscitate: during elective cesarean section
3. Ongoing assessment
4.Supplementary oxygen administration; For babies born at term, it is best to begin resuscitation with air rather than 100% oxygen.Administration of supplementary oxygen should be regulated by blending oxygen and air, and the amount to be delivered should be guided by oximetry.
5.Suctioning : There is no evidence that active babies benefit from airway suctioning, even in the presence of meconium, and there is evidence of risk associated with this suctioning. The available evidence does not support or refute the routine endotracheal suctioning of depressed infants born through meconium-stained amniotic fluid.
6.Ventilation strategies (no change from 2005)positive airway pressure may be helpful in the transitioning of the preterm baby. Use of the laryngeal mask airway should be considered if face-mask ventilation is unsuccessful and tracheal intubation is unsuccessful or not feasible.
7.Recommendations for monitoring exhaled CO2. Exhaled CO2 detectors are recommended to confirm endotracheal intubation.
8.Compression-to-ventilation ratio remains the same: The recommended compression-to-ventilation ratio remains 3:1. If the arrest is known to be of cardiac etiology, a higher ratio (15:2) should be considered.
9.Thermoregulation of the preterm infant should be considered (no change from 2005)
10.Postresuscitation therapeutic hypothermia: It is recommended that infants born at ≥36 weeksof gestation with evolving moderate to severe hypoxic-ischemic encephalopathy should be offered therapeutic hypo thermia.
11.Delayed cord clamping : There is increasing evidence of benefit of delaying cord clamping for at least 1 minute in term and preterm infants not requiring resuscitation. There is insufficient evidence to support or refute a recommendation to delay cord clamping in babies requiring resuscitation.
12.Withholding or discontinuing resuscitative efforts (Reaffirmed 2005 Recommendation): In a newly born baby with no detectable heart rate, which remains undetectable for 10 minutes, it is appropriate to consider stopping resuscitation,considering factors such as the presumed etiology of the arrest, the gestation of the baby, the presence or absence of complications, and the potential role of therapeutic hypothermia.
In adult post–cardiac arrest patients treated with therapeutic hypothermia, it is recommended that clinical neurologic signs, electrophysiologic studies, biomarkers, and imaging be performed where available, at 3 days after cardiac arrest. Currently, there is limited evidence to guide decisions regarding withdrawal of life support. The clinician should document all available prognostic testing 72 hours after cardiac arrest treated
with therapeutic hypothermia and use best clinical judgment based on this testing to make a decision to withdraw life support when appropriate. Explained as; on the basis of the limited available evidence, potentially reliable prognosticators of poor outcome in patients treated with therapeutic hypothermia after cardiac arrest include bilateral absence of N20 peak on somatosensory evoked potential more than or equal to 24 hours after cardiac arrest and the absence of both corneal and pupillary reflexes >3 days after
cardiac arrest. Limited available evidence also suggests that a Glasgow Coma Scale Motor Score of 2 or less at day 3 after sustained return of spontaneous circulation and presence of status epilepticus are potentially unreliable prognosticators of poor outcome in post-cardiac arrest patients treated with therapeutic hypothermia. Similarly, recovery of consciousness and cognitive functions is possible in a few post-cardiac arrest patients treated with therapeutic hypothermia despite bilateral absent or minimally present N20 responses of median nerve somatosensory evoked potentials, which suggests they may be unreliable as well. The reliability of serum biomarkers as prognostic indicators is also limited by the relatively few patients who have been studied.
EUROPEAN RESUSCITATION COUNCIL GUIDELINES: