New CPR guidelines

[Zan de Man]

American Heart Association Updated Emergency Care Guidelines
by


The guidelines were published online today in Circulation: Journal of the American Heart Association. They provide recommendations for how lay rescuers and emergency healthcare providers should resuscitate victims of cardiovascular emergencies. Topics include CPR, the use of automated external defibrillators (AEDs) and recommendations for advanced cardiovascular life support (ACLS) and pediatric advanced life support (PALS).

The 2005 guidelines emphasize that high-quality CPR, particularly effective chest compressions, contributes significantly to the successful resuscitation of cardiac arrest patients. Studies show that effective chest compressions create more blood flow through the heart to the rest of the body, buying a few minutes until defibrillation can be attempted or the heart can pump blood on its own. The guidelines recommend that rescuers minimize interruptions to chest compressions and suggest that rescuers "push hard and push fast" when giving chest compressions.

"The 2005 guidelines take a 'back to basics' approach to resuscitation," said Robert Hickey, M.D., chair of the American Heart Association's Emergency Cardiovascular Care programs. "Since the 2000 guidelines, research has strengthened our emphasis on effective CPR as a critically important step in helping save lives. CPR is easy to learn and do, and the association believes the new guidelines will contribute to more people doing CPR effectively."

The most significant change to CPR is to the ratio of chest compressions to rescue breaths -- from 15 compressions for every two rescue breaths in the 2000 guidelines to 30 compressions for every two rescue breaths in the 2005 guidelines. The 30-to-two ratio is the same for CPR that a single lay rescuer provides to adults, children and infants (excluding newborns). The change resulted from studies showing that blood circulation increases with each chest compression in a series and must be built back up after interruptions. The only exception to the new ratio is when two healthcare providers give CPR to a child or infant (except newborns), in which case they should provide 15 compressions for every two rescue breaths.

Another guidelines change emphasizing the importance of CPR is the sequence of rhythm analysis and CPR when using AEDs. Previously, when AED pads were applied to the chest, the device analyzed the heart rhythm, delivered a shock if necessary, and analyzed the heart rhythm again to determine whether the shock successfully stopped the abnormal rhythm. The cycle of analysis, shock and re-analysis could be repeated three times before CPR was recommended, resulting in delays of 37 seconds or more. Now, after one shock, the new guidelines recommend that rescuers provide about two minutes of CPR, beginning with chest compressions, before activating the AED to re-analyze the heart rhythm and attempt another shock. Studies have shown that the first AED shock stops the abnormal cardiac arrest rhythm more than 85 percent of the time and that a brief period of chest compressions between shocks can deliver oxygen to the heart, increasing the likelihood of successful defibrillation. The guidelines also recommend that healthcare providers minimize interruptions to chest compressions by doing heart rhythm checks, inserting airway devices, and administering of drugs without delaying CPR.

The new recommendations continue to encourage greater implementation of AED programs in public locations like airports, casinos, sports facilities and businesses. The 2005 guidelines reflect results of the Public Access Defibrillation trial, which reinforced the importance of planned and practiced response to cardiac emergencies by lay rescuers.

The new guidelines recommend that 911 dispatchers be trained to provide CPR instructions by phone and help callers correctly identify cardiac arrest victims. Dispatchers may walk rescuers through compressions-only CPR for most adult victims of cardiac arrest; however, instructions to do compressions and rescue breaths will be given for infants and children or adult victims of asphyxia, caused by near-drowning or other non-cardiac causes. Dispatchers also should be trained to recognize the symptoms of heart attack and other Acute Coronary Syndromes, and advise such patients to chew an aspirin while awaiting EMS.

To increase successful resuscitation, new guidelines advise EMS systems to evaluate their current protocols, shorten the response time for cardiac arrest patients, then document the impact of such changes on the number of lives saved.

The guidelines are based on the Consensus on Science and Treatment Recommendations (CoSTR), a document developed by the International Liaison Committee on Resuscitation. This group includes the American Heart Association and leading international resuscitation councils. The review of resuscitation literature reflected in CoSTR is the largest ever published. It took more than 36 months and includes input from 380 international experts CoSTR serves as the scientific basis for many countries' resuscitation treatment guidelines.

[CockySOB]

Excellent article, Zan. Thanks for posting it.

[Zan de Man]

The full list of changes, with rationale, are here.

[CockySOB]

IMO, everyone should know basic livesaving techniques including CPR.

[Zan de Man]

I was at a dinner last night celebrating the contribution of volunteers to life saving in the region I'm currently leading. We initiated a new Volunteer of the Month award and gave it to a husband and wife community responder team, who saved the life of an 80 year old lady who was in VF when they arrived. They were nominated by the paramedics who took over from them.

It was a great night with great people.

[suedanim]

The guidelines recommend that rescuers minimize interruptions to chest compressions and suggest that rescuers "push hard and push fast" when giving chest compressions.

I worry about cracking ribs and puncture of the lungs. I used to work on a cardiac team...waaaaaaaaaaaaay back.. Won't say how far back.. But, the emt's...literally straddled the patient and seemed to be doing jumping jacks on their chests! I know that cracked ribs ect were discussed a good bit.

What do you think, zan, of these home defibrillators? Also are there home cpr kits that compress the chest for you? One for a baby, one for an older child and one for adults?

[Diemos3211]

On another note, the trainer that did the CPR class I attended last said that he felt that rescue breaths should be relatively slow (i.e. the rescuer exhales more gently). It made some sense at the time (less chance of pushing lots of air into the stomach and having to deal with vomit for example), but I've been wondering about it and I'm especially questioning it in light of the article you posted in that giving more gentle rescue breaths took longer as this fellow was teaching it while I got the impression from the article that interupting compressions for longer than neccesary is bad.

[Zan de Man]

I think your teacher was extemporising Diemos. I used to teach CPR for Citizens and I've kept up with developments, but I've never heard that outside of infant CPR, where you fill your cheelks and squeeze them to puff the air into the baby's lungs.

The new range of simple automated external defibrillators (AEDs) is a great step forward Sue. I can remember when doctors were really cagey about letting paramedics use defibrillators, but nowadays they're first aid devices. We have a big programme in the UK for public access defibrillation at places where crowds gather and all of our community first responders have them.

Automatic cardiac compression devices vary. The first device was the Thumper, which also ventilated the patient. Among more modern devices is the Autopulse, which has just achieved some very poor results:

Humans outperform machines at CPR

Man appears to have beaten machine.

An automated CPR machine wasn’t faring as well as emergency responders in saving heart-patients’ lives, so researchers halted a study in Columbus and four other cities.

Starting in June 2004, 16 Columbus ambulances and one each in Worthington and Upper Arlington traveled with battery-powered Auto-Pulse machines. The machines, approved by the Food and Drug Administration and used regularly in several communities, are designed to perform cardiopulmonary resuscitation in place of a person. Many expected them to be more effective than people.

The study was to compare survival in 1,850 American and Canadian patients, half of whom would receive CPR from the machine, which straps around the patient’s chest. The other half would be treated in the traditional fashion, with paramedics and other emergency medical workers giving CPR.

But after nine months of study, which included 306 patients in the Columbus area, safety monitors alerted researchers: Fewer machine-treated patients were leaving the hospital alive.

"It was just the opposite of what we would anticipate happening," said Dr. Michael Sayre, an emergency physician at Ohio State University Medical Center and leader of the Columbus study.

Sayre and his colleagues shared the results yesterday at the American Heart Association’s annual Scientific Sessions in Dallas.

The study included 1,071 patients; 767 of them were considered the "primary" group because their emergency calls related specifically to heart problems. In that group, 373 were treated manually and 394 with the machines. The study included people from suburban Pittsburgh, Seattle, Vancouver and Calgary.

Four hours after the initial call to 911, a similar number had survived — almost 25 percent of those who got CPR manually and more than 26 percent of the AutoPulse group.

The problem was how many of the 767 left the hospital alive. About 10 percent of those initially treated manually and less than 6 percent of those treated by machine lived to go home.

A spokesman for Zoll, the Massachusetts-based company that sells AutoPulse machines, declined to comment. But a statement issued Friday by Zoll CEO Richard A. Packer said the trial was "disappointing because it was not completed." Packer called the results "inconclusive."

"We now better understand the challenges of such an effort, and we plan further research," he said in the statement.

Sayre said he had hoped that the consistent compressions delivered by the machine would beat people, who are prone to inconsistency and can tire during CPR.

"We really wish it would work," he said, pointing out that CPR rescues only a small percentage of heart patients.

There’s no solid answer why the results came out as they did, but Sayre had some theories. Training might not have been sufficient, he said. Medics watched a video and trained with the $14,000 machines, typically for a couple of hours, Sayre said. The problem with that theory is that outcomes should improve with experience, but the data show no learning curve.

Another possible explanation is that the time emergency responders must spend strapping a person into the machine and a subsequent delay in shocking them with a defibrillator was detrimental, Sayre said.

A more remote possibility is that the machine succeeded in circulating more blood and oxygen but that doing so was somehow harmful, Sayre said.

"There could be something going on that we don’t understand."


By
Misti Crane
THE COLUMBUS DISPATCH

We're currently conducting an evaluation of the Lucas CPR Device, which seems very promising indeed. It has performed well so far in clinical trials.

[sinterest]

Thank you! - thank you! thank you!
(from one who has to pack a lunch to go the his mail box and the mail man ages considerably getting to it).

I am very interested in opinions about affordable/practical defibrillators.
Me and my sweetie have been saving for a hot tub spa, but maybe this should come first.
I don't fear dying, but dread the thought of major brain damage and existing in a state of uncounsious drooling.

I look forward to reading more.

[Ms Digabit]

Are these guidelines going to be issued for the uk zan? i teach advanced life support to a range of multidisciplinary staff, as well as being a provider myself, and have noticed that there is not that much difference in the european guidelines as they stand and these american based ones.

The thumpers i believe, were mainly developed for pre hospital use by the paramedic, who is usually working by themselves in the back of the ambulance, it leaves them free to singularly manage the airway/arrest on the journey into hospital. staff mention they are awkward, bulky difficult to place and not user friendly.
Arrests in children are seldom cardiac,(usually respiratory)prolonged massage is rarely used and each child differs so much in weight, size and height that thumpers may be more detrimental then of benefit.

Sinterest, i hope you are not home alone,if anything untoward may happen, as it would be fairly impossible to defib yourself. id go for the spa..........die happy!!!

[Zan de Man]

Thumpers are out of use now Mrs D. The Lucas Device is a different animal and, as for as I know, designed for adults. Recent research has identified wide variation in CPR quality. You can probably regulate compression depth and frequency pretty accurately and fit in the required number of effective bag and mask ventilations, without interrupting compression, on a tubed or untubed patient. I've recently confirmed that I can still do it.

But most people who haven't taught it can't achieve these things.

The European/UK Resusctiation Councils and the American Heart Association have been converging their standards for about ten years and I've heard that these standards are due to arrive here any time.

However, they do differentiate between professionals and first aiders to a large extent. For the latter group, I think ventilations are going to become a thing of the past.

[sinterest]

Sinterest, i hope you are not home alone,if anything untoward may happen, as it would be fairly impossible to defib yourself. id go for the spa..........die happy!!!

I just love that responce. I normally prefer quality to quantity.

99% of the time my wife and I both are here together.

Where is a good place to learn more about defibs?

Googling always seems to just get me more confused if I don't have any starting criteria.

I'm hoping that you professionals can help me cut through the crap.

[Zan de Man]

Go and see the local EMS department. Most AEDs are pretty good these days. Ask them what they recommend and enrol in a class. You might be able to join a local first responder scheme and save some other lives locally.

If you draw a blank, try the Mecklenburg EMS Agency. I know they have a community education department. I can also stand over their quality.

[jpn of Seattle]

I'm trained to use the AED equipment at my work. Our trainer emphasized how important the AED or some kind of defibrilator is.
In fact, the person said that if you are alone with a heart attack victim, and you have to choose between giving CPR and running for help, you should run for help.
Because if the victim is in fibrillation, CPR doesn't do much good. The heart is spasming and chest compressions don't do much.
But if you don't have a defibrillator, then go ahead with CPR and hope for the best.

[Zan de Man]

Run for help quickly then get back to the patient. You've got four minutes to save their brain.

Heartstart Scotland is the biggest epidemiological study of out-of-hospital cardiac arrest in the world. Across the whole cohort of people found in VF, 10% survived to discharge from hospital. In the group who arrested in the presence of the ambulance crew, 39% survived. That rose to 43% in the group who got their first shock within 4 minutes of arrest.

CPR buys time. Defibrillation saves lives. But, if you don't have a defibrillator, get the ambulance on the way and start CPR. That way, there's a much better chance that the paramedics will have a viable patient to work on.

[cwinton]

This was covered here in the news, also.

Zan, I wanted to ask you something ... this will go beyond training and rely heavily on personal experience:

In the event of resuscitation from drowning:
-- lungs filled with fluid
-- training states pump-legs, begin CPR (respiratory)

At which point are bronchai filled with fluid? When respiratory-CPR begins and FORCES fluid deeper into these tiny pockets?

I am asking because it is not recommended to turn the drowning-victim upside-down, and it should be, PRIOR to attempting to re-inflate lungs.

[cwinton]

Oh, the 20-second delay, although seemingly an 'eternity,' could mean the difference between resuscitation or drowning-death, because the fluid is FORCED deeper by mouth-to-mouth. Even a couple of tablespoons is sufficient to KILL in error.

[Zan de Man]

Up to 15% of drowning patients don't have significant amounts of water in their lungs. They asphyxiate due to laryngeal spasm and are known as "dry drownings". For the rest, ventilation of the lungs is complicated by the presence of water.

However, don't get too clever: the basic rules for drowning or near-drowning are the same as for any other cardio-respiratory arrest: clear the airway and begin CPR. Some studies recommend the use of the Heimlich Maneouvre to remove water from the airways, but I haven't seen that make its way into mainstream practice yet.

[sinterest]

How does a kid that was submerged in "ice cold" water survive 20 minutes or so? In my time examples have made the national news several times.

[Zan de Man]

The UK's National Clinical Practice Guidelines for paramedics state that patients recovered from water should be resuscitated and conveyed to hospital unless immersion lasted longer than 3 hours, because survival from prolonged immersion is well documented.