AHA 2015 Guidelines: A Preview

On October 15, the new American Heart Association Guidelines for CPR and ECG will be published. Then we will get the answers to the big questions many of us have wondered about?

1. Has epinephrine in cardiac arrest seen its last days?

2. Should paramedics continue to intubate cardiac arrest patients?

3. Will traditional CPR be abandoned for cardiocerebral Resuscitation (CCR)?

Yesterday, the ILCOR Scientific Evidence Evaluation and Review System, in conjunction with the American Heart Association, published draft statements for public comment that shed light on the likely direction of at least some of these and other care questions.

The statements are available for public comment at the following link:

ILCOR Scientific Evidence Evaluation and Review System

Curiously the statements open for public comment do not seem to cover the full gamut of issues. There is only one statement on stroke care and no statement on continuous cardiac compressions (CCR).

Here are the answers to two of the above questions:

Epi in cardiac arrest

Full Question:
Among adults who are in cardiac arrest in any setting (P), does does use of epinephrine (I), compared with placebo or not using epinephrine (C), change Survival with Favorable neurological/functional outcome at discharge, 30 days, 60 days, 180 days AND/OR 1 year, Survival only at discharge, 30 days, 60 days, 180 days AND/OR 1 year, ROSC (O)?

Treatment Recommendation

Given the observed benefit in short term outcomes, we suggest Standard Dose Epinephrine be administered to patients in cardiac arrest.(weak recommendation, low quality)

Values and Preferences Statement:

In making this statement, we place value on the short-term outcomes of ROSC and survival to admission, and our uncertainty about the absolute effect on survival and neurological outcome.

Intubation

Full Question:
Among adults who are in cardiac arrest in any setting (P), does tracheal tube insertion as first advanced airway (I), compared with insertion of a supraglottic airway as first advanced airway (C), change ROSC, CPR parameters, development of aspiration pneumonia, Survival with Favorable neurological/functional outcome at discharge, 30 days, 60 days, 180 days AND/OR 1 year, Survival only at discharge, 30 days, 60 days, 180 days AND/OR 1 year (O)?

Treatment Recommendation:

We suggest using either a supraglottic airway or tracheal tube as the initial advanced airway management during CPR (weak recommendation, very low quality evidence) for out of hospital cardiac arrest.

Perhaps the most fascinating part about the draft statements is in the First Aid section, which includes the following statement on spinal restriction:

Full Question:
Among adults and children with suspected traumatic cervical spinal injury (P), does spinal motion restriction (I), compared with no spinal motion restriction (C), change neurological injury, complications, overall mortality, pain, patient comfort, movement of the spine, hospital length of stay (O)?

Treatment Recommendation:

We suggest against spinal motion restriction, defined as the reduction of or limitation of cervical spinal movement, by routine application of a cervical collar or bilateral sandbags (joined with 3-inch-wide cloth tape across the forehead) in comparison to no cervical spine restriction in adults and children with blunt suspected traumatic cervical spinal injury (weak recommendation, very low quality of evidence).

Values and preferences statement: Because of proven adverse effects in studies with injured patients, and evidence concerning a decrease in head movement only comes from studies with cadavers or healthy volunteers, benefits do not outweigh harms, and routine application of cervical collars is not recommended.

Let me repeat that. They are recommending against the routine application of cervical collars in patients with suspected spinal injuries.

Here in Connecticut, we have basically banned the use of back boards for anything but movement and extrication, but we still apply collars (despite lack of evidence of collar’s utility). Perhaps this statements will convince the rest of the world to end the unproven practice of spinal immobilization once and for all.

Please check this link out, and keep in mind these are draft statements only and they are seeking and will listen to public comment. This is a great and open process that we should participate in.

20 Comments

  • Steve says:

    The recent negativity regarding intubation is concerning. I believe that most medics gain profliency in evasive skills through repetive attempts. Not to sound insensitive, if we do not learn how to intubate dead patients, we will never learn how to intubate live patients.

    • Mark says:

      I think the question is whether there is any benefit to an ET tube vs. a supraglottic airway. From the studies I’ve seen, there doesn’t seem to be much of a benefit, if any.

    • Jeff says:

      If it’s not good for the patient proficiency is irrelevant.

    • Ellen Civitello says:

      While I understand the concern with ET intubation, I feel most of us have gotten quite proficient in ET placement! We’re taught that a subglottic tube (LMA) doesn’t protect & isolate the airway: I’m sure I’m not the only one who’s had a cardiac arrest patient vomit during CPR! Are you saying since the patient’s chances for survival are probably low, that protecting the airway is unecessary? I believe we need to provide the very best care to further increase those chances#

    • Chris says:

      I am a 25 year veteran firefighter/medic, and 9 year veteran critial care fixed wing medic. I work in Northeast Ohio. In this region, we have all but abandoned endotrachal intubation for the intent of ease of a superglottic airway. AHA de-emphasizing ETI and we have seen this coming for a while. We either bag the patient with no advanced airway device (so long as you are getting good compliance) or we drop a King LTD airway for a quick blind insertion and we are done – BOOM! simple as that. It works great for us. In my system we are within 10 minutes of two level one trauma centers, a level two pediatric trauma center, and a level three truama center. We work 95 % of our arrests on the scene, rather than transport a corpse with light and sirens and risk injuring or killing firefighters in doing so. Most of our arrests are “called” in the field and it seems to work fine. Why ETI if you don’t have to? There are quicker easier ways to gain an airway…

  • Sherri says:

    as an instructor of CPR in assisted living and memory care facilities, I am curious to know what changes may occur affecting how their staff responds to cardiac arrest until EMS and advanced care arrives. Will they still perform CPR with possible changes to guidelines?
    Staff in these facilities are not EMT level training, they perform CPR only currently and some basic first aid

  • Wayne says:

    THIS IS AWESOME. We just had this discussion at my primary agency the other day (re: spinal immobilization). I can’t wait until this finally catches on!

  • Sloan says:

    Steve, I’m not sure what you mean with your comment regarding intubation of “dead people” – I hope you aren’t so nihilistic such to say that patients in cardiopulmonary arrest are essentially cadavers and there for procedure practice. The “negativity towards intubation” you speak of is actually not negativity towards a procedure but a concern for the safety of our patients, and moreover, their outcome. Cheers, Sloan

  • Justin says:

    Steve, your thought process is profoundly flawed. CPR is not performed on dead people – that would be unethical according to the 2010 guidelines. If medics need intubation practice, then it should be on live patients in an OR or surgery center. If that is not available then they need to ugo with supraglottics.

  • Mike says:

    I like the King airway, but patients are not able to have a vent run through one at our hospital. It seems to me if you can successfully place an ET tube in the pre-hospital setting then the first thing that happens with the patient when we take them to the code room will not be the ER Doc pulling the King to place an ET tube. Seems like one less step and one less chance to cause unnecessary trauma to the patient’s airway.

    • Keith Balsamo says:

      As a paramedic and a RN working in the ED, I can say we do not pull EMS airways unless they are in improper placement. Why fix something that is not broken. EMS does need repetition to keep skills. If needed the airway can be changed under less stressful situations. Why not secure an airway and eliminate one thing that can break and have the opportunity to use continuous capnography.

  • RRT2Travel says:

    Mike, With use of a bougie a King airway can be easily exchaged for an ET tube once the patient is stable enough to do so. This has to be done for hospital legal reasons and documentation along with changing the securing device. The King is my favorite for this reason as it is quick and very hard for a responder to get wrong. No shame in using a King in the field, saved time is better for patient outcome.

  • Arthur Pearce says:

    What is the full question for ”3. Will traditional CPR be abandoned for cardiocerebral Resuscitation (CCR)?” and what is the ”Treatment Recommendation”?

    Everyone looks at supraglotic airways with dispise because it is stated that it cannot handle airway pressures above 40 mmHg and it is a high risk for gastric aspiration; this is wrong, as there are supraglotic airways which can handle higher pressures.
    To resolve this; recommendations to which supraglotic airway used should be made. For example the King LT-S and the LMA – Supreme can accommodate higher airway pressures and has a ”gastric fluid escape route”. And if airway problems still persist then revert from a-synchronised CPR to synchronised CPR as chest compressions is higher advocated than breathing, and if gastric aspiration is a problem then insert a nasal cannula via the ”gastric port” when needed.
    The major problem with intubation is that most of the time paramedics cannot tube while CPR is performed and then it leads to a 20 – 30 sec delay in compressions. That means that all resuscitative efforts up-till then is lost.
    The draft statements made is vague.

    • Arthur Pearce says:

      Sorry it should be Nasogastric tube and not nasal cannula.

    • BH says:

      If medics can’t intubate with CPR in progress they need to train until they can, or more correctly, can’t miss. At my level of care we don’t even intubate a live person before being licensed and I regularly intubate with a Lucas device running. It ain’t rocket science.

  • B Thompson says:

    Whether you are excellent at intubation or not is irrelevant. I can drop an iGel airway with an NG tube in a patient and apply the vent before most people could finish prepping for an intubation. That is the goal. Less time securing an airway and more time focusing on compressions, drug therapy, and reversing H’s, and T’s. If for some reason, and this has not happened to me yet, a problem arises with the iGel, then I can pass a Bougie through it and secure an ET tube in seconds.

  • I feel it would be to the patient’s benefit should we continue to place ET tubes, seeing that vomiting during CPR is a common occurance. What would it benefit the patient when he/ she is successfully resuscitated just to remain in hospital due to pneumonia secondary to aspiration.

  • Has anyone read the studies on raising the head during CPR? It decreases ICP by allowing fluids to drain out of the cranium. It’s not practical with manual CPR, but the Lucas makes this possible.

  • Ihunanya udochu says:

    Airway protection is important in a cardiac arrest patient especially endotracheal intubation unlike supraglottic airway which does not and there is risk of aspiration.A paramedic should learn how to intubate the trachea, pass an LMA and NG tube. Protecting the airway shouldn’t be enough, paramedics should know how to position his hands, and also the cardiac arrest patient for CPR.

  • Jeff B says:

    So tired of the “lowest common denominator” driving what we do.
    AHA cannot recommend ET placement because so many “medics” can’t tube a patient properly, usually because they only intubate 1-2 patients per year.
    In systems with the proper ratio of medics/population, your medics will get plenty of experience in placing ET’s, and the issues of taking too long/ can’t do it during CPR become laughable.
    We continue to write policies for the entire country without acknowledging that there is a HUGE discrepancy in the skill levels of ALS providers across the country.

Leave a Reply

Your email address will not be published. Required fields are marked *