Cardiopulmonary resuscitation and acute cardiovascular life support--a protocol review of the updated guidelines

For the first time in 5 years, new guidelines for cardiopulmonary resuscitation (CPR) of adults and children were introduced at the end of November 2005. The new CPR guidelines evolved from emerging evidence-based resuscitation studies and the evaluation process included the input of 281 international resuscitation experts who evaluated hypotheses, topics, and research over a 36-month period. The process included evidence evaluation, review of the literature, and focused analysis. This article reviews the four major changes to the guidelines. Changes are currently being made in the training of all new and recertifying ACLS health care providers.     

Researchers' Understanding of the Federal Guidelines for Waiver of and Exception from Informed Consent

The survival of patients who present to the emergency department with severe injury or illness is dismal. Resuscitation researchers are interested in advancing the science of resuscitation, and clinical studies must be conducted to determine the best treatment protocols. These studies must reflect good science and must balance individual patient autonomy and safety with scientific progress that benefits society as a whole. Researchers find the present federal guidelines on waiver of and exception from informed consent to be time consuming and expensive. They see variability in the requirements as interpreted by institutional review boards. There is confusion regarding the requirements for public notification and response to community consultation. They believe that the majority of the public, as well as health care professionals, want resuscitation research to progress, but a minority of people and governmental regulators are uncomfortable with waiver of and exception from informed consent for research studies. There is concern and some evidence that the federal guidelines have impeded the advancement of resuscitation science. Several strategies have been suggested to improve the situation. These include 1) better education of resuscitation researchers regarding the federal guidelines, 2) a toolbox for resuscitation researchers clarifying the guidelines, 3) advocacy for the advancement of resuscitation science as a public good, and 4) a national research advisory board that provides unbiased reviews of clinical studies and guidelines for local institutional review boards regarding risks, benefits, and communication strategies for waiver of and exception from consent proposals.     

An overview of the new resuscitation guidelines

New resuscitation guidelines contain significant changes intended to improve resuscitation practice and survival from cardiac arrest. The guidelines also include helpful new sections with guidance on in-hospital resuscitation. This article provides an overview of the key changes and discusses their practice implications for nurses.     

Advanced cardiovascular life support in AHA Guidelines 2010: Key changes from Guidelines 2005

In cardiopulmonary cerebral resuscitation (CPCR), advanced cardiovascular life support(ACLS) is a part of "chain of survival" and effects on resuscitation outcome as the interventions which increase the likehood of ROSC and as the continuing step to the post -cardiac arrest care. In order to build effective ACLS intervention, quality of basic life support is essential throughout the resuscitation effort. Based on quality CPR, ACLS providers should optimize the outcome by the integrated strategy that is consist of appropriate "drug therapy", qualified"advanced airway management", and accurate "physiologic monitoring". In this article, ACLS in American Heart Association(AHA) 2010 guidelines was reviewed and key changes from the 2005 guidelines are extracted. Not only guideline itself but training designed on the valid recommendations of guidelines are important to achieve competency of ACLS teams and better outcome of resuscitation.     

An alternative approach to advancing resuscitation science

Stagnant survival rates in out-of-hospital cardiac arrest remain a great impetus for advancing resuscitation science. International resuscitation guidelines, with all their advantages for standardizing resuscitation therapeutic protocols, can be difficult to change. A formalized evidence-based process has been adopted by the International Liason Committee on Resuscitation (ILCOR) in formulating such guidelines. Currently, randomized clinical trials are considered optimal evidence, and very few major changes in the Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care are made without such. An alternative approach is to allow externally controlled clinical trials more weight in Guideline formulation and resuscitation protocol adoption. In Tucson, Arizona (USA), the Fire Department cardiac arrest database has revealed a number of resuscitation issues. These include a poor bystander CPR rate, a lack of response to initial defibrillation after prolonged ventricular fibrillation, and substantial time without chest compressions during the resuscitation effort. A local change in our previous resuscitation protocols had been instituted based upon this historical database information.     

Automatic chest compression devices—when do they make sense?

The current resuscitation guidelines of the European Resuscitation Council do not include automatic chest compression devices (ACDs) as standard equipment to support cardiopulmonary resuscitation attempts. One possible reason could be the lack of a list of indications and contraindications for the use of ACD systems. This review should give a summary of current studies and developments according to ACD systems and deliver a list of possible applications. Furthermore, we discuss some ethical problems with cardiopulmonary resuscitation attempts and, in particular, with ACD systems. The use of ACDs occurs instead of manual chest compression. Because of this, there is no reason for changing the current guidelines, especially termination recommendations while using ACD systems. From our point of view, ACDs are a very good supplement to the current standard of resuscitation according to the European Resuscitation Council guidelines.     

Are the 2010 guidelines on cardiopulmonary resuscitation lost in translation? A call for increased focus on implementation science

Despite significant resources spent on rigorous evidence review and resuscitation guideline development, an important gap remains in our understanding of effective strategies and tools for implementing resuscitation guidelines. The lack of evidence about effective guideline implementation for resuscitation is likely reducing the impact of the incredible amount of work that goes into the production of such guidelines. This commentary draws attention to knowledge translation learnings from other content areas and within the area of resuscitation science to support a call for increased attention and innovation in implementation science as an equally important investment for the future of resuscitation medicine.     

Use of the Trendelenburg position as the resuscitation position: to T or not to T?

OBJECTIVE: To review the literature on use of the Trendelenburg position as a position for resuscitation of patients who are hypotensive. METHODS: PubMed online, cited bibliographies, critical care textbooks, and Advanced Cardiac Life Support guidelines were searched for information on the position used for resuscitation. Because of the heterogeneity of the data, only pertinent articles and chapters were summarized. RESULTS: Eight peer-reviewed publications on the position used for resuscitation were found. Pertinent information from 2 critical care textbooks and from the Advanced Cardiac Life Support guidelines was included in the review. Literature on the position was scarce, lacked strength, and seemed to be guided by "expert opinion." CONCLUSION: The general "slant" of the available data seems to indicate that the Trendelenburg position is probably not a good position for resuscitation of patients who are hypotensive. Further clinical studies are needed to determine the optimal position for resuscitation.     

Nurses’ attitudes towards resuscitation and national resuscitation guidelines—Nurses hesitate to start CPR-D

National resuscitation guidelines were published in Finland in 2002 and updated in 2006. The purpose of this study was to analyse the effect of cardiopulmonary resuscitation (CPR) education on attitudes towards defibrillation during arrests (CPR-D) and the guidelines.     

Why do chest compressions aid delayed defibrillation?

The new resuscitation guidelines permit compressions before delayed, defibrillation, a change that has generally been welcomed. The benefits are generally assumed to relate to the immediate provision of limited coronary perfusion with protection or replenishment of myocardial metabolic reserves. In this paper we argue that the concept is inadequate to explain many experimental and clinical observations made during resuscitation attempts. We argue that changes in the size and shape of the ventricles are the most important reason for the narrow window of opportunity for defibrillation alone and for the value of compressions in extending this period. We also draw attention to the implication for clinical resuscitation and to one aspect of the current guidelines of the European Resuscitation Council that we believe to be inconsistent with the evidence that we review.     

Documentation of resuscitation events

Resuscitation documentation assists health care professionals in trending patient status, determining what treatments may be most effective, and determining where opportunities for improvement may exist. An overview of what is known about resuscitation documentation is provided in this article, as are implications for future research related to documentation of resuscitation events. Use of the Utstein guidelines in determining essential elements of resuscitation documentation is also presented.     

Adherence to guidelines when positioning the defibrillation electrodes

BACKGROUND: Placement of the defibrillation electrodes affects the transmyocardial current and thus the success of a defibrillation attempt. In the international guidelines 2000, the placement of the apical electrode was changed more laterally to the mid-axillary line. Finnish national guidelines, based on the international guidelines, were published in 2002. OBJECTIVES: The purpose of this study was to determine to what extent health care professionals adhere to the new guidelines when positioning the electrodes. METHODS: Professionals were recruited from emergency medical services, university hospitals and primary care. Not revealing the purpose of the test, participants were asked to place self-adhesive electrodes on a manikin as they would do in the resuscitation situation and to answer a questionnaire about resuscitation training and familiarity with the guidelines. The distance of electrodes from the recommended position was measured in horizontal and vertical planes. RESULTS: One-hundred and thirty six professionals participated in the study, and only 25.4% (95% CI 18.5-32.9) of them placed both electrodes within 5 cm from the recommended position. The majority of the participants placed the apical electrode too anteriorly. Of the participants, 36.0% were not aware of the new guidelines. Awareness of the guidelines did not increase the accuracy in electrode placement. CONCLUSIONS: The publication of the national evidence based resuscitation guidelines did not seem to have influenced the practice of placement of the defibrillation electrodes to any major extent. The correct placement of the electrodes needs be emphasized more in the resuscitation training.     

Auditing resuscitation of preterm infants at birth by recording video and physiological parameters

ObjectiveTo evaluate compliance with neonatal resuscitation guidelines during resuscitation of preterm infants by video recording of delivery room management and monitoring physiologic parameters.MethodsThe delivery room management of preterm infants at birth was recorded by an independent researcher. Physiological parameters (airway pressures, gas flow, tidal volume, heart rate and oxygen saturation) were measured, use of supplemental oxygen was noted and a video of the resuscitation was recorded. All signals were digitised and recorded using specially designed software. The delivery room management was then evaluated and compared with the local resuscitation guidelines.ResultsThirty-four infants were included with a mean (SD) gestational age of 30.6 (3.2) weeks and birth weight of 1292 (570) g. Time from birth to initial evaluation was longer than recommended (65 (15) s). Respiratory support was started at 70 (23) s. In 7/34 infants (21%), interventions were performed according to guidelines. In 25/34 infants (74%), one or more respiratory interventions were not performed according to guidelines. In 10/34 infants (29%), one or more non-respiratory interventions (mainly related to the prevention of heat loss) were not performed according to guidelines. The presence and adequacy of spontaneous breathing was difficult to judge clinically. In almost all occasions (96%) the information from the respiratory function monitor was not used.ConclusionsNeonatal caregivers often deviate from resuscitation guidelines. Respiratory function monitoring parameters were often not used during resuscitation. A difficult part of neonatal resuscitation is subjectively assessing spontaneous breathing.     

Guidance for ambulance personnel on decisions and situations related to out-of-hospital CPR

Ethical guidelines on out-of-hospital cardio-pulmonary resuscitation (CPR) are designed to provide substantial guidance for the people who have to make decisions and deal with situations in the real world. The crucial question is whether it is possible to formulate practical guidelines that will make things somewhat easier for ambulance personnel. The aims of this article are to address the ethical aspects related to out-of-hospital CPR, primarily to decisions on not starting or terminating resuscitation attempts, using the views and experience of ambulance personnel as a starting point, and to summarise the key points in a practice guideline on the subject.     

Resuscitation outcomes comparing year 2000 with year 2005 ALS guidelines in a pig model of cardiac arrest

BACKGROUND: Ventricular fibrillation remains the leading cause of death in western societies. International organizations publish guidelines to follow in case of cardiac arrest. The aim of the present study is to assess whether the newly published guidelines record similar resuscitation success with the 2000 Advanced Life Support Guidelines on Resuscitation in a swine model of cardiac arrest. METHODS AND RESULTS: Nineteen landrace/large white pigs were used. Ventricular fibrillation was induced with the use of a transvenous pacing wire inserted into the right ventricle. The animals were randomized into two groups. In Group A, 10 animals were resuscitated using the 2000 guidelines, whereas in Group B, 9 animals were resuscitated using the 2005 guidelines. Both algorithms recorded similar successful resuscitation rates, as 60% of the animals in Group A and 44.5% in Group B were successfully resuscitated. However, animals in Group A restored a rhythm, compatible with a pulse, quicker than those in Group B (p=0.002). Coronary perfusion pressure (CPP) was not adversely affected by three defibrillation attempts in Group A. CONCLUSIONS: Both algorithms' resulted in comparable resuscitation success, however, guidelines 2000 resulted in faster resuscitation times. These preliminary results merit further investigation.     

Knowledge and attitude towards paediatric cardiopulmonary resuscitation among the carers of patients attending the Emergency Department of the Children's Hospital at Westmead

The present study aimed to describe the knowledge and attitudes of parents and carers in performing cardiopulmonary resuscitation on infants and children. A self‐administered questionnaire distributed to a convenience sample of parents and carers attending the Emergency Department of The Children's Hospital at Westmead, Australia from February to March 2008. Main outcome measures were the prevalence of previous cardiopulmonary resuscitation training, willingness and confidence to perform cardiopulmonary resuscitation on infants and children compared with adults, and an objective assessment of knowledge of current resuscitation guidelines. A total of 348 parents and carers were surveyed; 53% had received previous cardiopulmonary resuscitation training, 75% prior to the previous year. There was no significant difference on their willingness to perform cardiopulmonary resuscitation on an adult versus a child (75.6% and 75.8% respectively, P= 0.870). However, 81% were willing to perform cardiopulmonary resuscitation on a relative whereas only 64% were willing to perform cardiopulmonary resuscitation on a stranger (P < 0.001). Respondents were moderately confident in delivering cardiopulmonary resuscitation to a collapsed child; mean score of 2.9 on 5‐point Likert scale. Only 11% of respondents knew the correct rate for chest compressions and the ratio of compressions to ventilations; 8% had performed cardiopulmonary resuscitation in a real situation. Parents and carers are willing to perform cardiopulmonary resuscitation, especially on family members. However, their knowledge of the current guidelines was poor. More public education is required to update those with previous training and to encourage those who haven't to be trained.     

The ABC of resuscitation and the Dutch (re)treat

In 1982 the Netherlands made a unilateral decision to change the established airway-breathing-circulation (ABC) training sequence to a different approach that stressed efficiency in diagnosis and treatment. This Dutch approach became known as the CAB (circulation-airway-breathing) sequence. Twenty years later, being confronted with the new international guidelines (published 2000) that still use the ABC approach, the Netherlands Resuscitation Council (NRR) questioned again the validity of our persistence in using the "Dutch variant" of resuscitation. This resulted in revised national guidelines that conform again with the international guidelines. This article restates the main rationale and arguments behind the original decision to change to a Dutch (CAB) version of resuscitation over 20 years ago. The national decision to adopt the ABC approach once again was mainly to prevent resuscitation in the Netherlands from being isolated from the rest of the world and was not based on present knowledge of physiology and resuscitation. The authors hope that this article will open the discussion once again.     

Working together,nurses can make a difference in resuscitation outcomes: An update on the American Heart Association's 2010 guidelines for cardiopulmonary resuscitation and emergency cardiovascular care

The International Liaison Committee on Resuscitation (ILCOR) was formed in 1992 to provide a forum for resuscitation organizations worldwide. According to its mission, ILCOR provides a mechanism by which international science and knowledge that are relevant to cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) can be identified, reviewed, and evaluated. Every 5 years, based on a rigorous review of the published, peer‐reviewed science, ILCOR develops a consensus on resuscitation science and carries that forward into internationally agreed‐on treatment recommendations. As part of the 2010 evidence‐evaluation process, ILCOR published an updated consensus on science and treatment recommendations (CoSTR). Based on the CoSTR, the American Heart Association (AHA) developed and disseminated guidelines for ECC and CPR. Nursing has unique responsibilities in the chain of survival. This article reviews the major elements of AHA's 2010 guidelines and discusses the critical role that nurses play in the development, dissemination, and implementation of resuscitation science. By making the connection in resuscitation science, nurses can help to save more lives.     

Cardiopulmonary resuscitation standards for clinical practice and training in the UK

The Royal College of Anaesthetists, the Royal College of Physicians, the Intensive Care Society and the Resuscitation Council (UK) have published new resuscitation standards. The document provides advice to UK healthcare organisations, resuscitation committees and resuscitation officers on all aspects of the resuscitation service. It includes sections on resuscitation training, resuscitation equipment, the cardiac arrest team, cardiac arrest prevention, patient transfer, post resuscitation care, audit and research. The document makes several recommendations. Healthcare institutions should have, or be represented on, a resuscitation committee that is responsible for all resuscitation issues. Every institution should have at least one resuscitation officer responsible for teaching and conducting training in resuscitation techniques. Staff with patient contact should be given regular resuscitation training appropriate to their expected abilities and roles. Clinical staff should receive regular training in the recognition of patients at risk of cardiopulmonary arrest and the measures required for the prevention of cardiopulmonary arrest. Healthcare institutions admitting acutely ill patients should have a resuscitation team, or its equivalent, available at all times. Clear guidelines should be available indicating how and when to call for the resuscitation team. Cardiopulmonary arrest should be managed according to current national guidelines. Resuscitation equipment should be available throughout the institution for clinical use and for training. The practice of resuscitation should be audited to maintain and improve standards of care. A do not attempt resuscitation (DNAR) policy should be compiled, communicated to relevant members of staff, used and audited regularly. Funding must be provided to support an effective resuscitation service.     

Are the new resuscitation guidelines optimal?

PURPOSE OF REVIEW: The purpose of this review is to evaluate the 2005 guidelines on cardiopulmonary resuscitation. RECENT FINDINGS: International guidelines are based ideally on results from robust clinical trials. They are necessarily constrained in how far they can draw conclusions from experimental data, and have to pay regard to perceived safety and educational issues. Informed opinion can be more radical in drawing from compelling recent experimental findings, particularly when supported by unreplicated or indirect clinical evidence. Those already available cover a range of issues relevant to the guidelines; the most important ones are reviewed here. SUMMARY: The 2005 guidelines represent a major advance on those previously in use, but on the evidence already available they cannot be considered optimal. Deviations based on good evidence should not be discouraged provided they are approved and preferably monitored by authoritative bodies that should see this as a legitimate role in developing the science of resuscitation medicine. Guidelines for the most pressing of medical emergencies should not be set and inflexible over several years whilst the science behind them continues to advance.