Insufficient Evidence

The 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiac Care Science with Treatment Recommendations were published on October 18. At the same time the American Heart Association published its 2010 Guidelines largely based on this document.

As I have written previously, I await these releases every five years with great excitement. I had particular interest for this edition based on much of the new research in areas such as cardio cerebral resuscitation and airway.

Having now read the Executive Summary as well as other parts of the document, I have to say my initial reaction was disappointment.

As far as real news there is very little:

The document does reconfirm the necessity of good compressions. It speaks of the four metrics of CRP: “adequate rate, adequate depth, allowing full chest recoil after each compression and minimizing pauses (e.g, hand off time) in compressions.”

As far as CPR goes, rescuers should now “begin resuscitation with compressions rather than opening the airway” and delivering breaths.

Chest compressions should now be at least 2” in adults.

There is support for induced hypothermia, including for patients resuscitated from non-VF/VT rhythms.

Procainimide is back for VT with pulses.

The routine use of high flow 02 in Acute Coronary Syndrome is not recommended. 02 should be titrated to SAT.

Capnography is hailed.

Prehopital 12-leads and cath lab activation are encouraged.

These nuggets aside, the document can best be summarized by the recurrent phrase:

“There is insufficient evidence to recommend for or against… (fill-in-the-blank).”

There is insufficient evidence to recommend for or against the use of any mechanical devices during CPR.

There are still no data showing that any drugs improve long-term outcome after cardiac arrest.

There is insufficient evidence to support or refute a delay in defibrillation to provide a period of CPR for patients in VF/pulseless ventricular (VT) for cardiac arrest.

There are no data to support the routine use of any specific approach to airway management during cardiac arrest.

There is insufficient evidence to support or refute the use of passive oxygen delivery during CPR to improve outcomes when compared with oxygen delivery by positive pressure ventilation.

There is inadequate evidence to define the optimal timing or order for drug administration.

I could go on.

Now a week after reading the document, I have to say, I do admire the document’s honesty and believe that this is a better, if less satisfying approach. While we are all always looking for the latest magic bullet, we do want our medicine to be evidenced-based, and we have to recognize that approach is not always compatible with instant gratification.

The document ends with a brief paragraph called Future Directions:

The science of resuscitation is evolving rapidly. It will not be in the best interests of patients if we wait 5 or more years to inform healthcare professionals of therapeutic advances in this field. ILCOR members will continue to review new science and, when necessary, publish interim advisory statements to update treatment guidelines so that resuscitation practitioners may provide state-of-the-art treatment. Existing gaps in knowledge will be closed only by continuing high-quality research into all facets of CPR.

I applaud them for this.

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Here is the link to the full AHA Guidelines.

2 Comments

  • David says:

    What a disappointment. 5 years to wait for this? We have been doing continuous chest compression CPR with passive only ventilation since 2005 and our findings from a busy busy EMS system have found a dramatic increase in survival rate to hospital admission AND discharge with neurologically intact outcomes with CCC and passive only ventilation. Our data has been incorporated with that from other cities doing exactly this. The research is there. The papers have been published starting in 2006 and are frequently cited.

    The AHA is teaching hands-only uninterrupted CPR for the lay perosn. It’s frustrating to know we are doing the right thing and seeing that the AHA is not endorsing it.

    As a prehospital provider, I think the emphasis is far too much on physician and lay person oriented research. We shoot for the high end and the low end, forgetting the EMS aspect.

    I have watched countless codes in the hospital and it’s far too much talk, too much debate, too much fuss, too much pomp and circumstance during codes. If it’s not a witnessed code in an ICU, I would not want to code anywhere in the hospital.

    But this is exactly the environment the AHA seems to focus on. They talk about the importance of the EMS system for stroke and STEMI, but that’s about it.

    In our system, we have all but abandoned ACLS except for licensure purposes. Not because ACLS is bad, but because it is not evolving at an appropriate rate. It seems that the AHA has plateaued with respect to forward looking and devolved into a “let’s keep everyone happy” approach.

    I think you will see a continued departure from ACLS as the Gospel because EMS systems need something better for them. ACLS has a place — the hospital. We need a Prehospital Cardiac Life Support.

  • I agree with David about PHCLS, if that’s what we’re going to call it. ACLS still focuses on in hospital personnel and situations without much effort spent on pre hospital care.

    It’s also nice to see the AHA abandoning the five year window on changes. Resuscitation science is rapidly evolving and as with David’s system, mine uses treatments and techniques that were not in the 2005 guidelines. In fact, we’ve used and abandoned a couple that weren’t in the 2005 guidelines and aren’t in the 2010 ones either. They looked good, but didn’t pan out. Which might actually be an argument for being more deliberative.

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