Authors: Neumar RW et al., Circulation 2015 Nov 3; 132:S315
Push hard and fast — but not too hard or too fast!
Sponsoring Organization: American Heart Association (AHA)
Target Population: Lay public, healthcare providers
Background and Objective
The AHA has released an evidence-based update to its 2010 guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care.
Adult basic life support (BLS):
- Bystanders should initiate compression-only CPR.
- Compression rate should be 100–120 per minute (updated from “at least” 100 per minute).
- Compression depth should be 2–2.4 inches (upper limit added).
- Compression time should be maximized.
- Feedback devices may be used to optimize compression rate and depth.
- Social media may be used to summon rescuers to perform CPR.
Adult advanced cardiovascular life support (ACLS):
- Vasopressin is out; stick with epinephrine.
- Extracorporeal CPR is an alternative to CPR in patients for whom the suspected etiology is reversible.
- Maximize oxygenation during CPR, but titrate down after return of spontaneous circulation (ROSC).
- After 20 minutes of CPR, a low end-tidal CO2level may be used to help determine whether to terminate resuscitation in intubated patients.
- Ultrasound may be used to confirm endotracheal tube placement.
- After ROSC:
- Consider lidocaine if arrest is due to ventricular fibrillation/tachycardia.
- In comatose patients, target temperature to 32–36°C for at least 24 hours, and prevent fever.
Emergency cardiac care:
- A high-sensitivity troponin I level <99th percentile at 0 and 2 hours in a low-risk patient (Thrombolysis in Myocardial Infarction I score of 0 or 1) predicts <1% chance of 30-day major adverse cardiac event).
- A negative troponin I or T at 0 and 3–6 hours in a very low-risk patient (Vancouver score of 0) predicts <1% chance of 30-day major adverse cardiac event.
The 2010 recommendations focused on increased compression depth and speed, but now we have good evidence that too much of either is bad. In addition, new technologies (e.g., extracorporeal membrane oxygenation, high sensitivity troponin assays, CPR feedback devices, social media) are included, and vasopressin is finally out again.
These well-written updates incorporate new evidence while acknowledging areas in which evidence is still lacking. Given that these updates will soon be incorporated into BLS and ACLS training, it is important to know about them so that we can effectively lead resuscitation teams (and avoid blank looks when erroneously ordering vasopressin).