ILCOR Guidelines Changes (2010)
3/1/11
Jason Feng’s Presentation
Highlights from the 2010 AHA Guidelines for CPR and ECC ->
ILCOR – International Liaison committee on Resuscitation
= conglomerate of resuscitation councils worldwide
-
AHA
European Resuscitation Council
Heart and Stroke Foundation of Canada
Australia and New Zealand Committee on Resuscitation
Resuscitation Councils of South Africa
Inter American Heart Foundation
Resuscitation Council of Asia (Japan, Korea, Singapore, Taiwan)
CHANGES IN 2010 GUIDELINES
Compressions Emphasis
-
CAB rather than ABC
minimise interruptions
allow complete chest recoil
atleast 100/min rather than approximately 100/min
compression depth: at least 5cm in adults and 4cm in infants
no change in ratios: 30:2 adults and children (with children can go to 15:2)
avoid excessive ventilation
Basic Life Support
-
immediate recognition of unresponsiveness and activation of emergency response services
initiation of CPR if unresponsive or not breathing normally
look-listen-feel removed
good quality CPR (push hard, push fast)
Advanced Life Support
- emphasis in minimizing duration of pre and post shock pauses
- CPR should not stop > 5 seconds
- early defibrillation (1 better than 3 stacked shocks) -> with immediate resumption of CPR is
the important variable
- AED’s in hospitals and for children and infants now
- if initial shock unsuccessful -> give same or greater energy
- no CPR device has been shown to be superior to manual CPR
- precordial thump only for witnessed but should not delay defibrillation or CPR
- early intubation with minimal disruption to CPR (then continuous CPR with breaths 10/min)
- capnography recommended: ET tube placement, quality of CPR and detection of ROSC
- drugs:
-> atropine not recommended for PEA/asystole
Jeremy Fernando (2011)
-> adrenaline 1mg Q 3 min
-> amiodarone 300mg after 3rd shock
-> don’t use ETT for drugs (IV or IO)
-> adenosine used for diagnosis and treatment of unstable, undifferentiated, regular,
monomorphic wide-complex tachycardia (don’t use in irregular wide-complex tachycardia)
- cardioversion:
-> AF: 120-200J (biphasic), 200J (monophasic)
-> atrial flutter: 50-100J (bi or monophasic)
-> stable VT: 100J (bi or monophasic)
Post Cardiac Arrest Care
- optimize cardiopulmonary function and perfusion
- transport to appropriate hospital (cath lab, neurological care, goal directed critical care,
hypothermia)
- identify and treat precipitating causes
- avoid hyperoxia (SpO2 >94% but not 100%)
- primary PCI is appropriate in the comatosed with ROSC
- glucose < 10mmol/L
- therapeutic hypothermia
- traditional measures of prognosis @ 72 hrs are now not as predictive given benefits seen of
therapeutic hypothermia.
- monitor for and treat seizures
Paediatric Life Support
- CAB (ERC still advocates 5 initial rescue breaths)
- good quality CPR
- removal of ‘look, listen, feel’
- de-emphasis on pulse check
- AED and defibrillation use encouraged (infants manual defibrillation)
- capnography recommended
- defibrillation: 2-4 J/kg
- avoid hyperoxia
- congenital heart disease: early use of ECMO advocated
- calcium use: only in hypocalcaemia, Ca2+ channel blocker OD, hypermagnasaemia,
hyperkalaemia
Acute Coronary Syndromes
-
out of hospital 12 lead ECG: reduce time to thrombolysis and PCI
cardiac arrest and ACS if ischaemic in origin -> requires PCI (coma is not a contraindication)
if saturations > 94% don’t require O2
chest pain: use nitrates, use morphine cautiously (associated with increased mortality)
Stroke
- don’t manage BP pre-hospital
- improved outcomes with management in stroke unit
- rtPA within 3 hours of selected cases
Jeremy Fernando (2011)
Neonatal Resuscitation
- ABC resuscitation
- 3:1 compression to ventilation ratio (unless CVS in origin then 15:2)
- use of SpO2 on right wrist or palm (colour unreliable)
- start ventilation with air -> titrate O2 up (avoid hyperoxia)
- no need to suction vigorous babies (suction those with airway obstruction, obtunded or
meconium)
- capnography encouraged
- therapeutic hypothermia (33.5-34.5 C)
- delayed cord clamping for 1 min beneficial in babies not requiring resuscitation
Ethical Issues
- cessation of care: BLS (unwitnessed, no ROSC after 3 complete rounds (6min), no shocks
indicated/delivered), ALS (unwitnessed, no bystander CPR, no ROSC after complete ALS, no
shocks delivered)
- prognostication difficult now as the work was done prior to therapeutic hypothermia
SUMMARY OF CHANGES
Compression’s emphasis
-
CAB vs ABC
early, high quality, uninterrupted
atleast 100/min (rather than around)
avoid excessive ventilation
Basic Life Support
- early call for EMS and starting of CPR (unresponsive and abnormal breathing)
- look-listen-feel removed
- ‘push hard, push fast’
Advanced Life Support
-
minimise pauses in CPR
early defibrillation (higher joules for cardioversion)
capnography
no atropine
no ETT drugs (IV or IO)
adenosine for unstable, undifferentiated, wide-complex tachycardia
Post cardiac Arrest Care
-
transport to definitive and ICU care
PCI in comatosed with ROSC
therapeutic hypothermia
avoid hyperglycaemia and hyperoxia
ID and treat cause
Jeremy Fernando (2011)
- treat seizures
Other Issues
- paediatrics: AED use encouraged, congenital heart disease -> ECMO early
- neonates: ABC, 3:1, air -> titrate O2 up, don’t suction vigorous babies, therapeutic
hypothermia, delayed cord clamping in those not compromised good
- ACS: field 12 lead ECG good, nitrates, caution with opioids
- stroke: tPA within 3 hours, don’t manage BP acutely, stoke units
- ethics: prognostication tools difficult to use know c/o therapeutic hypothermia, stopping
advice
Jeremy Fernando (2011)