The American Heart Association (AHA) recently released new guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiac care.1 These guidelines, based on the latest comprehensive review of resuscitation science by the International Liaison Committee on Resuscitation, emphasize streamlined algorithms and recommendations to reduce the amount of information rescuers must learn and to emphasize the most important skills they must master. The complete guidelines, released in December 2005 as a special supplement to the journal Circulation, are available online at http://circ.ahajournals.org/content/vol112/24_suppl/.
The new guidelines are based on the work of eight task forces that addressed specific areas of resuscitation science: basic life support, advanced life support, acute coronary syndromes, life support for children, neonatal life support, stroke, first aid, and education. These groups used an evidence-based approach to classify the recommendations for CPR and emergency cardiac care. The guidelines also present 12 algorithms covering the essential assessments and interventions for cardiac arrest and other life-threatening conditions.
The authors of the guidelines cite some key lessons learned about CPR that helped guide formulation of the new guidelines: (1) to be effective, CPR must be started as soon as possible after a person collapses; (2) the best results with lay rescuer CPR have occurred in the presence of trained and motivated bystanders with short response times and readily available automated external defibrillators (AEDs); (3) studies have shown that even during asphyxial arrest, chest compressions alone are better than doing nothing; and (4) lay bystanders often are reluctant to perform CPR because they think that it has been made too complicated or that their training is inadequate, or they fear the transmission of disease during mouth-to-mouth resuscitation.1ppIV12-18
For basic life support and CPR, the guidelines continue to emphasize the "ABCD" approach to acute cardiopulmonary arrest: Airway, Breathing, Circulation, Defibrillation. Because CPR must be started as soon as possible to be effective, and because it often is performed poorly by both lay bystanders and health care professionals, the recommendations for child and adult CPR have been consolidated and simplified. To simplify age classifications, the new recommendations for lay rescuers classify persons as children (ages one to eight years) or adults (older than eight years), whereas the recommendations for health care professionals classify persons as preadolescents (ages one to 14 years or until the presence of secondary sex characteristics) and adults.1ppIV12-18 To simplify teaching and ensure longer periods of uninterrupted chest compressions, a universal compression-ventilation ratio of 30:2 (i.e., 30 compressions followed by two breaths) is recommended in nearly all situations except infant resuscitation and two-rescuer child CPR. It has been observed that lay rescuers often are unable to accurately determine whether circulation is present, and so may not provide chest compressions when they are needed. For this reason, lay rescuers are not asked to assess for signs of circulation before beginning chest compressions, nor are they expected to provide rescue breathing without chest compressions.1ppIV19-34,IV156-166 The key emphasis of the guidelines is "push hard, push fast, allow full chest recoil, and minimize interruptions in chest compressions."
The new algorithm for adult basic life support (Figure 1) recommends the following sequence when a rescuer finds an unresponsive person: (1) call for help and an AED (if available); (2) open the adult's airway, check for breathing, and give two breaths if he or she is not breathing; (3) start cycles of 30 compressions and two breaths (100 compressions per minute); (4) on arrival of a defibrillator or AED, check for a shockable rhythm (ventricular fibrillation or tachycardia); (5) give one shock (if indicated), then resume CPR for another five cycles, or if no shock is indicated, continue another five cycles of CPR before rechecking the rhythm. Health care professionals are to check for a pulse after the initial breaths (step 2) and continue with one rescue breath every five or six seconds if there is a pulse, but this step is not recommended for lay rescuers.1ppIV19-34
Basic Life Support for Adults
Figure 1. Algorithm for basic life support for adults. (AED = automated external defibrillator; ALS = advanced life support; CPR = cardiopulmonary resuscitation.)
Adapted with permission from American Heart Association. 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2005;112(24 suppl):IV19.
The new algorithm emphasizes minimizing interruptions to chest compressions to maximize the benefits of compressions: shocks are to be given singly with immediate resumption of CPR rather than as stacked shocks; pulse checks are minimized; and when interventions such as medications or an advanced airway are needed, the emphasis is on minimizing interruptions to CPR (ideally, 10 seconds or less).1ppIV1-5 Because stacked electrical shocks are no longer recommended for ventricular fibrillation or pulseless ventricular tachycardia, a single energy dose is recommended for all defibrillation attempts: 200 joules on a biphasic defibrillator or 360 joules if the defibrillator is monophasic.1ppIV35-46
The new guidelines also highlight the importance of integrating AED use and CPR to facilitate rapid defibrillation. Because the most common rhythm in witnessed cardiac arrest is ventricular fibrillation, the guidelines recommend adequate training of lay rescuers in AED use, adequate provision of AEDs in settings where sudden cardiac arrest may occur, and sending for and using an AED or defibrillator as soon as possible after a witnessed arrest. One notable exception is that for an unwitnessed arrest, health care professionals may provide five cycles of CPR before attempting defibrillation; this approach was shown to improve survival rates in two clinical studies. It is thought that for a heart in prolonged fibrillatory arrest, these initial cycles of CPR may help by providing fresh blood flow to cardiac cells that have depleted their local supplies of oxygen and nutrients, thus increasing the likelihood of a stable rhythm following the defibrillatory shock.1ppIV35-46
There are few changes to the recommendations for managing cardiac arrest beyond the initial stages of CPR. Although there is no evidence that vasopressors or antiarrhythmics improve long-term survival rates, vasopressors have been shown to favor return of spontaneous circulation, and amiodarone (Cordarone) has been shown to improve survival rates prior to hospital admission. Thus, for persons who have pulseless electrical activity or asystole, or those in ventricular fibrillation who have not responded to an initial defibrillatory shock, intravenous (IV) or intraosseous (IO) access should be established as soon as possible. Administration of epinephrine (1 mg IV or IO) every three to five minutes is recommended for persons with pulseless electrical activity, asystole, or persistent ventricular fibrillation, and vasopressin (Pitressin, 40 units IV or IO) continues to be an option to replace the first or second dose of epinephrine. Amiodarone and lidocaine (Xylocaine) are recommended as second-line therapies for persistent ventricular fibrillation. However, the primary emphasis remains the provision of adequate CPR (Figure 2).1ppIV58-66
Advanced Life Support for Adults with Pulseless Cardiac Arrest
Figure 2. Algorithm for advanced life support for adults with pulseless cardiac arrest. (CPR = cardiopulmonary resuscitation; AED = automated external defibrillator; IV = intravenous; IO = intraosseus; J = joules.)
Adapted with permission from American Heart Association. 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2005;112(24 suppl):IV58.
The guidelines continue to emphasize that cardiac arrest in children is most often the end result of respiratory arrest. Thus, in contrast to adult CPR recommendations, a lone rescuer for an unresponsive child should begin with five cycles of 30 compressions and two breaths, then activate the emergency medical services system. This approach is thought to optimize the chances for quick resuscitation of children with primary respiratory arrest, before complete cardiopulmonary arrest occurs. Two-rescuer CPR in children is the only situation that deviates from the 30:2 ratio recommended for compressions and breaths; for two-rescuer CPR in children, two breaths should be given after every 15 compressions. Otherwise, CPR recommendations for children closely parallel those for adults (Figure 3).1ppIV156-166
Basic Life Support for Children
Figure 3. Algorithm for basic life support for children. (AED = automated external defibrillator; CPR = cardiopulmonary resuscitation; ALS = advanced life support.)
Adapted with permission from American Heart Association. 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2005;112(24 suppl):IV156.
Guidelines for advanced life support for children also are similar to those for adults, with a few notable exceptions: (1) vasopressin and atropine are not recommended for pulseless arrest in children; (2) the use of child dosing for defibrillation (if possible) is advised (4 joules per kg on a manual defibrillator or an AED with a child dose attenuator); and (3) the use of IO access is advised if IV access cannot be established quickly (Figure 4).1ppIV167-187
Advanced Life Support for Children with Pulseless Cardiac Arrest
Figure 4. Algorithm for advanced life support for children with pulseless cardiac arrest. (CPR = cardiopulmonary resuscitation; AED = automated external defibrillator; IV = intravenous; IO = intraosseus; J = joules.)
Adapted with permission from American Heart Association. 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2005;112(24 suppl):IV167.
Other notable changes to the guidelines for CPR and emergency cardiac care include:
All rescue breaths, whether by mouth, mask, or endotracheal tube, should be given over one second, with sufficient volume to produce visible chest rise.1ppIV19-34,IV156-166
For newborn resuscitations, it is acceptable to start with 100 percent oxygen or a lower concentration, although supplemental oxygen should be available if the infant does not improve within 90 seconds of birth.1ppIV188-195
Updated recommendations for managing acute coronary syndromes and stroke.
Discussions of special resuscitation topics including electrolyte abnormalities, drowning, hypothermia, near-fatal asthma, anaphylaxis, electric shock, and cardiac arrest associated with trauma or pregnancy. There also is a discussion of ethical issues involved in resuscitations.
William E. Cayley, Jr., M.D., M.Div., is assistant professor at the University of Wisconsin Eau Claire Family Medicine Residency Program.
Address correspondence to William E. Cayley, Jr., M.D., M.Div., University of Wisconsin Eau Claire Family Medicine Residency, 617 W. Clairemont, Eau Claire, WI 54701 (e-mail: email@example.com). Reprints are not available from the author.
1. American Heart Association. 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2005;112(24 suppl):IV1-203.
Practice Guideline Briefs
The American College of Obstetricians and Gynecologists (ACOG) Committee on Health Care for Underserved Women has released recommendations to improve health care of homeless women. The recommendations were published in the August 2005 issue of Obstetrics & Gynecology.
Approximately 3.5 million Americans are homeless, and one third of these persons are women. Homelessness increases the risk of injury and illness and results in high rates of mortality. More than two thirds of homeless mothers have mental illness, and posttraumatic stress disorder, substance abuse, and depression are significantly more common in homeless women than in other populations. About 26 percent of homeless women report having "survival sex," and almost two thirds reported using no method of contraception despite having sex at least once per week. Homeless women, especially those with mental illness, have about a 10 percent greater chance of being raped than the general population. Pelvic inflammatory disease affects 28 percent of homeless women, and 60 percent have had at least one sexually transmitted disease (STD). Pregnancy rates are higher among homeless women, and these women have significantly higher rates of adverse birth outcomes than the general population.
In the past year, nearly 25 percent of homeless persons who needed medical attention were unable to obtain health care, and homeless women are less likely to have mammography and Papanicolaou tests than the general population. To implement obstetric and gynecologic care guidelines recommended by the ACOG, the committee suggests that communities develop organized services directed specifically to the homeless population. The committee recommends the following actions to improve health care for homeless women:
Provide unbiased care for homeless women in individual practices.
Volunteer to provide health care services at homeless shelters and soup kitchens. Adherence to treatment is enhanced when medical care is coupled with services to meet the survival needs of patients. Care should not be withheld because of concerns about lack of adherence.
Seek donations of medications from pharmaceutical companies for use in homeless clinics and shelters.
Work with local hospitals and clinics to implement health care programs for the homeless.
Work with medical schools and residency programs to encourage modification of the educational curriculum to increase awareness of the problems associated with homelessness and to involve medical students and residents in care for homeless persons as part of their training.
Assess current community programs for homeless persons and advocate for improved coordination of services between these programs and other special programs (e.g., prenatal care, immunization, tuberculosis treatment, STD clinics, mental health care, housing and legal aid).
Advocate for professional liability protections for physicians who volunteer their services to the homeless.
Encourage federal, state, and local governments to provide adequate funding for the provision of comprehensive health care services, including mental health treatment for all homeless persons.
Copyright © 2006 by the American
Academy of Family Physicians.