New International Consensus on Cardiopulmonary Resuscitation

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New International Consensus on Cardiopulmonary
Resuscitation

• Catrina Hewitt
• Dec 2005

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Development

• 2000 guidelines in resuscitation published, and
  circulation formed basis for 1st International
  Resuscitation Guidelines.
• Review process in 2004/2005
• Led by International Liaison Committee on
  Resuscitation.
• Culminated in the 2005 International Consensus
  Conference on Emergency Cardiovascular Care and
  Cardiopulmonary Resuscitation Science with
  treatment recommendations.

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• The final document produced formed the basis for
  the European Resuscitation Guidelines.
• The guidelines adopted by Resuscitation Council
  (UK) are an abbreviated version of the ERC
  guidelines.
• They differ from other international
  organisations in only minor ways.

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Why Change?

• Chest compressions provide circulatory support
  during cardiac arrest, and hold the key to
  survival when definitive treatment can not be
  given within 4-5 minutes.
• Most often the case for resuscitation out of
  hospital.
• 80 of cardiac arrests occur out with hospital
  setting.

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• Studies show that number, rate and quality of
  chest compressions are usually far from optimal
• Number of compressions may be most important
  factor, and easiest to correct.
• Compressions are interspersed with ventilations
  at a ratio of 152, compression rate 100 per
  minute

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• Number of compressions delivered in a minute are
  important.
• Recent UK study showed median rate of
  compressions to be 120 a minute
• Average number of compressions delivered per
  minute is only 38
• Due to
• Excessive time to deliver ventilations
• Delays and pauses by rescuers
• Analysis time required by automated defibrillators

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New guidelines

• Emphasise need for training to avoid unnecessary
  delays

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Changes

• Describe more simply how to place hands on the
  chest
• Ratio of 302
• No longer give rescue breaths
• Compressions for 2 minutes after defibrillation,
  even before a pulse check
• Single shock by defibrillation

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BLS

• Make a diagnosis of cardiac arrest if a victim is
  unresponsive and not breathing normally
• Place hands in the centre of the chest, rather
  than using rib margin technique
• Give each rescue breath over 1 second instead of
  2
• Use ratio of 302 for all adult victims. Use same
  ratio for children when attended by a lay rescuer
• For an adult, omit initial 2 rescue breaths and
  give 30 compressions immediately after cardiac
  arrest is established.

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BLS

• In the reluctance to perform mouth-to-mouth,
  compression only CPR is encouraged
• It is effective for a limited period of time
  (5 minutes)
• Not recommended treatment of out-of-hospital
  arrest.

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BLS Algorithm
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BLS exceptions

• Children
• Drowning
• Both ventilation and compression are important
  for victims when O2 stores depleted, 4-6 minutes
  after VF, immediately after collapse from
  asphyxia
• 5 initial rescue breaths before starting
  compressions
• If alone, perform CPR for 1 minute before going
  for help

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Automated external defibrillators

• Electrical defibrillation is the only effective
  treatment for cardiac arrest caused by VF or
  pulseless VT
• Delay from collapse to delivery of the first
  shock is the most important determinant of
  survival
• Chances of successful defibrillation decline at a
  rate of 7-10 with each minute of delay
• BLS will help maintain a shockable rhythm but is
  not a definitive treatment

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AED Changes

• Continue CPR whilst paddles are being applied
• Single shock given
• 150-360 J Biphasic
• 360 J Monophasic
• Immediately resume CPR for 2 minutes, no rhythm,
  breathing or pulse check

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AED Algorithm
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Adult ALS Algorithm
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Why Change?

• No published studies comparing single shock to 3
  shock protocol for treatment of VF/VT
• Experimental studies show that short
  interruptions on chest compressions to deliver
  rescue breaths or check rhythm are associated
  with reduced survival
• Using three shock protocol (time taken to deliver
  shocks, and analyse rhythm) cause significant
  disruption to CPR

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• First shock efficacy of biphasic waveforms
  exceeds 90
• Failure to terminate VF/VT implies need for CPR
  to improve myocardial oxygenation
• If defibrillation is successful in restoring a
  perfusing rhythm, pulse is unlikely to be
  present immediately, delay in trying to palpate a
  pulse will further compromise myocardium if
  perfusing rhythm has not been restored. Giving
  chest compressions does not increase chance of VF
  occurring

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• For biphasic defibrillators, initial shock should
  be 150J. If unsuccessful, 2nd shocks may be given
  at higher energy level, no evidence to suggest
  either a fixed or escalating energy protocol
• For monophasic defibrillators, lower efficacy for
  terminating VF/VT, it is recommended initial
  shock of 360 J. 2nd and subsequent shocks should
  remain at 360J

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Adrenaline

• No placebo controlled study to show that the
  routine use of any vasopressor at any stage
  during cardiac arrest to increase the survival to
  hospital discharge
• Current evidence is insufficient to support or
  refute the routine use of any particular drug or
  sequence of drugs
• Despite the lack of human data the use of
  adrenaline is still recommended based on
  experimental data
• The alpha-adrenergic actions of adrenaline cause
  vasoconstriction, increasing the myocardial and
  cerebral pressure

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• Ideal time to give adrenaline
• Immediately after confirmation of the rhythm and
  just before delivery of the shock
  (drug-shock-CPR-rhythm check)
• Avoid delay between stopping chest compressions
  and delivery of the shock
• Adrenaline given immediately before a shock will
  be circulated by the CPR following the shock
• Give adrenaline prior to alternate shocks

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Anti-Arrhythmic Drugs

• No evidence that giving anti-arrhythmic drugs
  routinely in cardiac arrest increases survival to
  hospital discharge
• Compared to placebo and lignocaine, the use of
  amiodarone in shock refractory VF/VT improves
  survival to hospital discharge
• No evidence on use of amiodarone after single
  shock refractory VF/VT
• Expert consensus, if VF/VT persists after 3
  single shocks, give 300mg amiodarone prior to 4th
  shock

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Any Questions ?