I’m like a kid before Christmas waiting for the new AHA CPR and ECC guidelines to come out. For almost a year I have been following the evidence sheets posted on the Heart Association web site, and nearly everyday in November checked the site for the new guidelines to be posted. When they finally came out over a week ago, I downloaded them and have been pouring over them. The guidelines are exciting to me because they represent the synthesis of expert’s opinions after reviewing all the studies of the last five years, they give a glimpse of how EMS will be in the near future and they are full of instructive PEARLS. (Reading them line by line is an excellent educational learning experience. My copy of the 2000 guidelines is heavily highlighted and dog-eared.) Also, as someone involved in writing my region’s protocols, I am interested in how they may have to be rewritten.
There are some interesting changes in the new guidelines, some of which have already made the news:
CPR for lay people is now 30 compressions to 2 respirations for adults instead of 15:2.
When EMS response to a cardiac arrest is 4-5 minutes or when EMS responders did not witness the arrest, EMS providers may do 2 minutes of CPR prior to defibrillation.
1 shock instead of 3 stacked: Rescuers should resume CPR immediately after shocking and continue for 2 minutes before checking for pulse or to shock again. Rescuers should continue CPR during the charging phase of defib until time to clear.
The first shock should be 360 monophasic or 150-200 for biphasic.
The focus is on compressions. “Simply put: rescuers should push hard, push fast, allow full chest recoil, minimize interruptions in compressions, and defibrillate promptly when appropriate.”
Ventilations should be 8 to 10 per minute in the intubated patient in arrest; 10 to 12 with a perfusing rhytmn.
Pacing for asystole is no longer recommended.
Unless special siuations are present (hypothermia)”cessation of efforts in the out-of-hospital setting, following system-specific criteria and under direct medical control, should be standard practice in all EMS systems.”
Cardiac arrest associated with Trauma
If intubation is performed in the field, it should be done during transport.
Volume infusion for trauma is recommended only for patients with isolated head or extremity trauma with goal of systolic >100.
Lidociane is no longer in the algorithm for tachycardia with pulses. It’s amiodarone.
Rapid afib has new language that says “we recommend expert consultation if the patient is stable.” The phrase runs throughout the section. “Stable patients may await expert consultation because treatment has the potential for harm.”
Nitro has new restrictions in the setting of ACS. No nitro for heart rates less than 50 and more than 100. And no nitro if the BP is 30 mm Hg below patient’s baseline, rather than just below 90 mm Hg.
Steroids should be administered to all asthma patients as early as possible.
Epi 1:1000 should be administered IM not SQ.
I am anxious to discuss the new guidelines at our MAC meeting next week and hear other people’s opinions.
Much of it makes sense to me. The focus on compressions I think is huge. As I have written before I have been on many scenes where CPR just doesn’t get done. Someone’s going for the tube, someone’s going for the IV, someones getting the board and no one is on compressions. And it seems everytime I come upon a code where only first responders are there, all I hear is the defib unit going, “checking pulses, if no pulses…” and everyone just standing there. When compressions do get done, they are often done poorly. When I started really focusing on compressions, my save rate (at least rate to the hospital with pulses) went up considerably.
I worry a little about the ventilations not getting done. I also worry about people getting shocked as they want compressions to continue even when the defib is charging. Still I’m for the changes. What we have right now isn’t working very well. Hopefully this will be better.
From a medic standpoint I was a little discouraged that I got a bit of an anti-medic feeling reading the guidelines. Now let me say, I believe these guidelines are pro-patient, and anything pro-patient has to also be pro-medic because medics are for what is best for the patient. What I mean is that so much that medics do seems to be being discredited — and maybe for the best. From fluid rescusitation for trauma, to intubation(the text is full of caution about the pitfalls of intubation), to the curious language of seeking “expert consultation,” the message seems to be just take them to the hospital without harming them. You can’t argue with “Do No Harm” if it is harm that we have been doing.
On the other hand, there is full recognition that if we can’t bring someone back in the field, they will not be brought back in the ED. (It is time to end futile resuscitations and senseless transports of dead people.)
I believe in and trust experts, I just hope however that there were medics or at least pro-medic people at the table to see that the evidence was interpreted in a way that wasn’t biased against what we do, or interpreted with a proper understanding of what and how we do what we do.
Lastly, I must say just because the meds we give during codes haven’t been proven to work doesn’t mean medics aren’t worth anything. It means the meds aren’t worth anything. I believe medics are very important, but they are only as good as their education, their training, their oversight, and the equipment, meds, and tools they are given to do the job.
And a link to all the abstracts:
There are three publications that can be downloaded:
Eventually, I’m guessing in the spring, the AHA will be selling paperbound copies of the guidlines and science as they have done in the past.