Other notes
Cerebral stabilization during the post-resuscitation period
Cardiovascular stabilization
Cellular or neuronal stabilization
Maintain normal BP (MAP=70-90mmhg)
Normalize blood volume CVP=10-15cm H2O
Use invasive monitoring in unstable patients
Maintain adequate O2 carrying capacity (Hb 10-12g/dl) and saturation >94%
Elevate bed end 10-30˚
Avoid hyperthermia (>38˚C)
Control or avoid seizures (diazepam, phenytoin and barbiturates)
Metabolic stabilization (BSL, electrolytes)
Immobilization (neuromuscular paralysis as indicated)
Sedation as needed
Targets:
PaO2 ≥ 80-100mmhg (avoid excessive PEEP)
PaCo2 = 30-35mmhg
pH = 7.35-7.45
Glucose 5-10mmol/L
Serum osmolality 280-320 mosm/kg
Avoid hypoproteinemia
Consider therapeutic hypothermia for 48-72hrs
Medications to consider if indicated: Ca-channel blockers Nimodipine
Guidelines for informing the family of unexpected death
Preparation – room, social services and clergy informed if needed
Notification – introduction, control, address most stable closest relative, sit down if possible (unless hostile),
join the group if feasible. Short succinct and clear delivery of the death news.
Grief response – 30-60 secs for settling in of the news; provide comfort if possible. Ask about knowledge of
preceding events, discuss history.
Do not answer questions about quality of care if any issues raised, ask for time for information gathering.
Reassure family about what could be done was done, if appropriate. Address guilt issues for family
members, if present.
Address grief issues in staff and ambulance staff if any.
Conclusion – clergy/social service introduction if present. Explain further tasks – coroner notification, private
physician etc. direct funeral arrangement and other issues towards social service.
Ask about transplant issues, autopsy requirements and need for viewing. Express availability to answer
queries at a later stage if needed. Express sorrow for the loss and need for further support. Complete
necessary hospital/state and legal procedures/papers.
Viewing the body – confirm body is prepared for viewing, staff are prepared and make sure staff member
accompanies them and is informed of the progress and past events.
Departure - arrange follow up for any grief counseling if needed. Do not treat for stress response without
registration.
Arrange debrief for staff
ILCOR 2010 changes to 2005 guidelines
New 2010 recommendation
Old 2005 recommendation
Basic life support
Comments
Bystander not trained in CPR
should provide hands-only CPR –
‘push hard, push fast’. Trained
rescuers should at least conduct
hands-only CPR and if able do
30:2 CPR ratio with breaths
Change in CPR sequence CAB
rather ABC – Initiate
compressions before ventilations
No specific recommendations for
trained and untrained providers.
Suggested hands-only CPR, provide
ventilations if able to under
instructions.
Hands-only CPR is easier to
perform, easily guided over the
phone. Similar survival rates
between hand0only CPR and CPR
with compressions + ventilations.
CPR began with opening of the
airway, checking for normal
breathing, and then delivery of 2
rescue breaths followed by cycles
of 30:2
“Look, listen, and feel” removed
from the CPR sequence. After
delivery of 30 compressions, the
lone rescuer opens the victim’s
airway and delivers two breaths
Perform chest compressions at
the rate of at least 100/min.
“Look, listen, and feel” was used to
assess breathing after the airway
was opened.
No evidence for old approach.
Although evidence to show delay
in compressions result in increased
mortality in animal and human
studies. Airway can occur if 2
rescuers present.
Due to change in sequence to CAB,
airway is only checked briefly in
any unresponsive victim after
delivery of 30 compressions.
Adult sternum should be
depressed at least 2 inches (5cm)
Adult sternum should be
depressed approximately 11/2 to 2
inches (4-5cm)
Compress at a rate of about
100/min.
Most studies show more
compressions associated with
better chance of ROSC. Stress
needs to be made on reducing
interruptions to compressions and
thus change in the wording to at
least 100/min.
Changed to avoid confusion
regarding depth and to encourage
increased depth. Most studies
show inadequate depth used in
CPR as reason for inadequate
output.
Advanced life support
Changes to wording of dispatcher
identification of agonal gasps –
increased emphasis
Dispatcher should provide
instructions for untrained
rescuers to provide hands-only
CPR.
Previous recommendation for
instructions ambiguous about
hands-only CPR.
The routine use of cricoid
pressure in cardiac arrest is not
recommended
Cricoid pressure should only be
used if the victim is deeply
unconscious and a third rescuer is
available.
Emphasis on “push hard push
fast”, hands-only CPR for lay
rescuers and chest compressions
+ rescue breaths for EMS
providers
The HCP should check response of
No different instructions for
different providers. Hands-only
CPR suggested to lay rescuers if
reluctant to give rescue breaths.
The HCP first activated the EMR
Considerable regional variation in
identification and dispatcher
recognition of agonal respirations
in past as criteria for early CPR.
Similar rates of ROSC with handsonly or conventional CPR noted
from studies. Reluctance to give
CPR due to inhibitions to provide
breaths causes delays in CPR.
Seven studies to show that cricoid
pressure may cause delays in
gaining airway control and some
aspiration of gastric contents may
still occur despite its use.
Hands-only CPR easier to perform
and easier for dispatchers to guide
over the phone.
The HCP should not delay CPR but
victim and check breathing
pattern before activating EMR.
and then returned to victim to
open airway, check airway and
breathing for normal or abnormal
breathing.
CAB rather than ABC for HCP CPR
as well
Elimination of “Look, listen, and
feel” for breathing
ABC approach for HCP CPR.
Compression rate at least
100/min
Compression depth at least 2
inches (5cm)
Team resuscitation – emphasis on
team member actions → activate
EMR, second begins
compressions, 3rd provides
ventilation, 4th retrieves AED.
Community lay rescuer AED
programs
AED use now includes infants
<1yr. Use pediatric AED for
age<8yrs, if unavailable an AED
without dose attenuator may be
used.
1 shock protocol with CPR
recommended over three-stacked
shock protocol.
Any dose 2 or 4 j/kg may be used
for first shock in pediatric VF. For
ease of teaching 2005 guidelines
may be followed.
Electrode placement – any of the
four positions are acceptable.
Anterior-lateral, AP, anterior-left
infrascapular and anterior-right
infrascapular.
AP and AL positions generally
acceptable in patients with
implantable pacemakers and
defibrillators. Avoid placing pads
or paddles directly over the
device.
Dose recommendation for
cardioversion: biphasic
“Look, listen and feel” for
breathing prior to initiation of CPR
sequence
Compression rate at about
100/min
Compression depth between 11/2
to 2 inches (4-5cm)
Sequential steps similar with less
emphasis on team building
Electrical therapies
Changed wording
AED recommendations similar
except use in age<1yr where no
evidence was cited.
Similar recommendation.
Pediatric defibrillation
First shock 2j/kg, all subsequent
shocks 4j/kg.
Default anterior-lateral position
and other positions described.
Position pad at least 1 inch (2.5cm)
away from the device.
No recommended dose for
biphasic defibrillators – data not
two pieces of information can be
obtained simultaneously while
activating EMR and retrieving AED
if available or sending someone to
retrieve it.
Evidence as in BLS
recommendation
Reduced delay in delivery of
compressions in victim with
cardiac arrest.
“Push hard, push fast, push deep”
Reduced confusion, single
recommendation.
Team response with clear role
delineation likely to result in better
outcomes.
Emphasis on provision of AED in
public places and importance of
organizing, planning, training,
linking with EMS and establishing
QA programs
Lowest and highest safe doses for
defibrillation in pediatrics are not
know but no adverse effects have
been found between 4-9j/kg doses
in pediatric and animal studies.
Two more studies comparing 3stack shock protocol vs. single
shock + CPR approach found better
outcomes with single shock
approach.
No data to recommend one
voltage over the other. Voltages
up to 9j/kg used in studies not
linked with any adverse outcome
Studies have shown the four
positions described in 2010
recommendations equally as
effective.
Studies show 8cm distance may
prevent damage to defibrillator
device from shock. AED may
confuse spikes from pacemaker
and not deliver shock.
Recommendation softer so that
focus is on preventing delay in
delivering shock.
More data available now for
recommending biphasic
Atrial fibrillation – 120-200J
Atrial flutter/SVT – 50-100J Stable
monomorphic VT – 100J
Monophasic dose 200J for AF and
50-100J for flutter.
Polymorphic VT/pulseless VT –
high energy unsynchronized
shocks similar to VF (200J)
Precordial thump should not be
used for unwitnessed out-ofhospital arrest. Consider for
monitored pulseless VT if AED not
immediately available – should
not delay shock delivery or CPR.
available.
defibrillator doses.
No previous recommendation
2 large studies showing no
effectiveness of precordial thump
on ROSC + risk for complications –
sternal fractures, osteomyelitis,
stroke and triggering malignant
arrhythmias in adults and children.
Advanced cardiac life support
Capnography recommendation –
An exhaled carbon dioxide
continuous waveform
detector or an esophageal
Capnography is now
detector was recommended to
recommended for intubated
confirm endotracheal tube
patients throughout the periarrest placement.
period for confirmation of tube
placement, monitoring CPR
quality and detecting ROSC.
Simplified circular ACLS algorithm Box and arrow algorithm showing
to emphasize on importance of
sequential steps.
high-quality CPR of adequate rate,
depth, allowing complete chest
recoil after each compression,
minimizing interruptions and
avoiding excessive ventilation
De-emphasis of devices, drugs and distracters
Medication protocols
Atropine not recommended for
Atropine was included in
routine use in management of
PEA/asystole algorithm.
PEA/asystole.
Adenosine was only recommended
Adenosine recommended in the
for narrow complex regular reinitial diagnosis of stable
entrant SVT.
undifferentiated regular,
Chronotropic infusions were
monomorphic wide complex
recommended after use of
tachycardia (not for irregular
atropine or while awaiting pacer or
rhythms)
if pacing failed.
Chronotropic drug infusions are
recommended as alternative to
pacing in unstable bradycardias
Organized post-cardiac arrest care
Cardiopulmonary and neurologic
Therapeutic hypothermia only
support. Therapeutic hypothermia recommended for ROSC post VF
and PCI provided when indicated. arrest. Other interventions
EEG for diagnosis of seizures
suggested but with limited
recommended in post-arrest
evidence.
period and thereafter regularly
monitored in patients with ROSC.
Tapering of FiO2 after ROSC based No specific recommendation or
on SaO2 – goal to maintain ≥94%
information.
to avoid hyperoxia while
providing adequate oxygenation.
Continuous Capnography is most
reliable method of confirming and
monitoring correct placement of
ETT and also to detect
displacement during transport and
detecting ROSC.
Re-affirming basics and
importance on key aspects known
to improve outcome.
Studies showing no therapeutic
benefit from using atropine in
PEA/asystole. Also studies proving
the other interventions work.
Two studies in patients with ROSC
post PEA/asystole arrest show
benefit from focused organized
post-cardiac arrest care including
therapeutic hypothermia.
SaO2 of 100% may represent PO2
between 80-500mmhg with a
significant risk for hyperoxia.
Five new topics added to existing
ten – 15 total special
circumstances. New include –
morbid obesity, pulmonary
embolism, avalanche, PCI, cardiac
tamponade and cardiac surgery.
Supplementary oxygen is not
needed for patients without
evidence of respiratory distress if
the SaO2 is ≥ 94%. Morphine
should be given with caution to
patients with unstable angina.
Special resuscitation situations
Old topics which continue to be
included – Asthma, anaphylaxis,
pregnancy, electrolyte imbalance,
ingestion of toxic substances,
trauma, accidental hypothermia,
drowning, electric shock/lightning
strikes
Acute coronary syndromes
Both interventions were
recommended.
Recognition of specific changes
needed to BLS/ALS/ACLS in the
new categories.
Not enough evidence to support
O2 supplementation to nondyspnoiec patients and morphine
use associated with increased
mortality in large registry study.
Pediatric life support
All adult recommendations now to cover pediatric BLS/ALS as well.
CAB rather than ABC, hands-only BLS, 30:2 and 15:2 for 1/2 rescuers ratio, depth 4cm for most infants and
5cm for most children. “look, feel, and listen” removed, pulse check de-emphasized. AED doses 2-4j/kg,
Capnography recommended as in adults. Oxygen use limitations introduced. SaO2 goal of ≥ 94%,
therapeutic hypothermia between 32-34˚ as in adults recommended
Wide complex tachycardia
Wide complex tachycardia defined PALS guidelines, >0.09s for <4yrs
redefined as QRS width
as QRS duration >0.08 seconds.
of age, >0.1s for 4-16 years.
>0.09seconds
Calcium use to be restricted to
Old recommendation did not
Stronger evidence about risk of
only overdose, hypermagnesemia, strictly rule out use but stated risk
harm from routine calcium use in
or hyperkalemia.
for harm.
CPR.
Neonatal life support
No need for neonatologist to be
present at all C-section deliveries,
but need for competent
resuscitators as need for BMV in
these neonates increased.
Assessment to include HR, RR and
state of oxygenation
No old recommendation
Assessment to include HR, RR and
evaluation of colour
Neonates born from C-section not
any more likely to require
intubation/CPR but more likely to
need BMV if pre-op assessment
rules out fetal distress.
Evaluation of colour very
subjective and data to show pulse
oximeter more sensitive.
Term babies have SaO2 of <60% at
birth and take 10 minutes to reach
100%. Hyperoxia can be toxic
especially to preterm baby.
Pulse oximetry to be applied to
If cyanosis, bradycardia or distress,
right upper extremity and used to 100% O2 supplementation was
assess need for O2, start with 21% indicated.
and titrate upwards as needed.
Suctioning advised only for babies All the following were indicated for
with signs of obvious obstruction. infants with distress or reduced
In case of gross meconium
response/breathing/pulse
staining no evidence to state
suctioning with laryngoscope
provides any benefit.
ETCO2 recommended as in adults and pediatric ALS/BLS
Optimal compression-to-ventilation ratio 3:1 unless cardiac cause for arrest then 15:2. Therapeutic
hypothermia to be considered for infants ≥ 36weeks with evolving moderate to severe hypoxic-ischemic
encephalopathy.
Delayed cord clamping in babies requiring resuscitation.