Inservice in the Breakroom: New ACLS Guidelines – Part 1

The American Heart Association released the 2010 Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) earlier this month. We can look at the different guidelines in subsequent posts, but this month, we’ll review the Executive Summary. The summary stresses the changes from prior recommendations.

The most evident change is the stress put on high-quality chest compressions started early. Survival is best improved by (1) calling EMS early, (2) early chest compressions and (3) early defib.

Recognizing that most lay people are unwilling or unable to provide mouth-to-mouth is part of it, but more importantly starting chest compressions FIRST is shown to improve surival. So now they are flipping the primary survey from A-B-C to C-A-B, putting “C” (chest compressions) first. Instead of “look, listen and feel” for ventilation, positioning the airway and providing two rescue breaths and then giving compressions, now start with 30 chest compressions and give breaths afterward (it should only take about 18 seconds).

“Hands-only CPR” (no ventilation) can be explained to untrained people over the phone, even. That’s right, no more mouth-to-mouth on gross vomit-encrusted bearded guys. Unless you’re into that. In fact, don’t even waste time looking for a pulse. If you insist, don’t waste no more than 10 seconds checking.

They even changed the v-fib/v-tach diagram into a circle which stresses the importance of early, quality CPR.

Here’s a summary of a few other things that changed:
– we should be using waveform capnography to measure exhaled CO2. Countless other studies have showed that ETCO2 is an earlier predictor of ventilatory failure than pulse oximetry. We don’t have this.
– Paramedics should be doing pre-hospital 12-lead EKG’s and informing the receiving hospital of the results. Any ST-elevations should prompt activation of the cath lab. Chicago may be getting this, according to Louie.
– Ambulances should take stroke patients to stroke centers and admitted to stroke units. We got these, but are they all being brought here?
– Cardiac care doesn’t end with restoration of spontaneous circulation (ROSC), but they’ve introduced new post-arrest algorithms. These are team-based approaches meant to optimize perfusion, early catheterization, post-arrest hypothermia and monitoring for organ failure.
– In PEA, no atropine
– In asystole, no transcutaneous pacing
– They also briefly mentioned family presence in resuscitations. Go Sarah!

They also include changes to first aid administered by lay people. They
– shouldn’t be giving aspirin
– shouldn’t be giving epinephrine (apparently people do this in some places)
– shouldn’t be giving oxygen (doesn’t help that much anyway)
– shouldn’t be applying tourniquets (though it has been helpful in Iraq and Afghanistan)
– should be using pressure immobilizer for poisonous and non-poisonous snake bites. They’re addressing snake bites?!
– Electrolyte solution PO hydration for dehydration

Okay next time – part 3 – the ethical consideration. Feel free to comment below.

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