Highlights of the 2010 AHA Guidelines for CPR and ECC

[RWC130 594]

Highlights of the 2010 American Heart Association

Guidelines for CPR and ECC

Click on link below

AHA Highlights for 2010

Thoughts?

[ckroll 101]

Highlights of the 2010 American Heart Association

Guidelines for CPR and ECC

Click on link below

AHA Highlights for 2010

Thoughts?

I've been reading the back papers to the recomendations, and it's interesting. While lidocaine has an effect on VF, overall mortality increases with it. Amiodarone, in limited studies, shows no improvement at low doses and is harmeful at high doses. Short version is antiarrythmics are Class III, not recommended.... to quote:

"Following an episode of VF, there is no conclusive data to support the use of lidocaine or any particular strategy for preventing VF recurrence. Further management of ventricular rhythm disturbances is discussed in Part 8.2: "Management of Cardiac Arrest" and Part 8.3: "Management of Symptomatic Bradycardia and Tachycardia."

[Circulation Nov 2010 Part 10 Managemenrt of Arrythmias]

But that's not why I posted.....And this is a 'charged' question..... More and more evidence is mounting that ANY interruption of compressions is harmful with longer interruptions being worse. And yet there still is this block of time where we do not do compressions while defibrillating.

Why? While I would not ask a fellow rescuer to continue compressions with a shock imminent, I've started doing them myself and through gloves, I'm just not feeling it. Are we missing an opportunity to improve outcomes when we hold off on compressions during active defibrillation?

Anybody out there have experience they could share?

[FD828 77]

Maybe you just got lucky that you didn't feel it. I however am not risking my well being or that of any member of my crew. If you want to continue compressions while the monitor is charging that is cool with me, but after that, hands off. Deliver the shock and go back to work if necessary. Our safety is the #1 priority.

[helicopper 1,050]

Maybe you just got lucky that you didn't feel it. I however am not risking my well being or that of any member of my crew. If you want to continue compressions while the monitor is charging that is cool with me, but after that, hands off. Deliver the shock and go back to work if necessary. Our safety is the #1 priority.

Gotta agree with you, FD. There are entirely too many variables that may influence the situation so I wouldn't jeopardize my safety - or the safety of my peers - to attempt compressions during a defibrillation.

On this point though, how do we address stairs and small elevators and other situations where it is near impossible to effectively perform compressions during patient movement? These situations take a whole lot more time than a shock.

[FD828 77]

Gotta agree with you, FD. There are entirely too many variables that may influence the situation so I wouldn't jeopardize my safety - or the safety of my peers - to attempt compressions during a defibrillation.

On this point though, how do we address stairs and small elevators and other situations where it is near impossible to effectively perform compressions during patient movement? These situations take a whole lot more time than a shock.

IMO the best thing to happen to EMS in the recent future has been the new CPR machines. We have the LUCAS and I have to say it is awesome. The battery lasts for approximately 45 mins (according to the rep) and you hook it up and it does the work. The correct amount and rate of compressions every time. You can set it for 30:2 to allow for ventilations if the patient is not intubated or you can set it to continue compressions non stop. A very worthwhile purchase.

[ckroll 101]

IMO the best thing to happen to EMS in the recent future has been the new CPR machines. We have the LUCAS and I have to say it is awesome. The battery lasts for approximately 45 mins (according to the rep) and you hook it up and it does the work. The correct amount and rate of compressions every time. You can set it for 30:2 to allow for ventilations if the patient is not intubated or you can set it to continue compressions non stop. A very worthwhile purchase.

And yet, devices are not improving outcomes.... and the real concern is that setting up devices may be taking time away from useful CPR. Energy seeks the path of least resistance, which is pad to pad. Locked hands, even on a bare chest, are unlikely to offer a better path to ground. General [ and perhaps unreasonable] fear of electricity should not be influencing patient care. If safety were the only issue, then find another line of work than EMS, which has many opportunities to be unsafe. What we are looking for as EMS providers is maximum effect with minimum risk. As the case becomes more compelling for continuous CPR, I'll ask again.... how long are we taking away from CPR to shock and is it necessary?

[FD828 77]

And yet, devices are not improving outcomes.... and the real concern is that setting up devices may be taking time away from useful CPR. Energy seeks the path of least resistance, which is pad to pad. Locked hands, even on a bare chest, are unlikely to offer a better path to ground. General [ and perhaps unreasonable] fear of electricity should not be influencing patient care. If safety were the only issue, then find another line of work than EMS, which has many opportunities to be unsafe. What we are looking for as EMS providers is maximum effect with minimum risk. As the case becomes more compelling for continuous CPR, I'll ask again.... how long are we taking away from CPR to shock and is it necessary?

From what you say, maybe you did get shocked a few times and didn't realize it!! Are you insane? I understand that there are risks in EMS, but taking UNNECESSARY risks is just plain stupidity. I also believe that you are mistaken about the results of the CPR machines. (I will look for concrete data) Not to mention it makes the stopping CPR to carry down stairs or just move the patient a thing of the past. The machine performs compressions better then ANY EMT/Medic, and the best part is it doesn't get tired. Each and every compression is the correct depth and at the correct rate.

[Goose 188]

From what you say, maybe you did get shocked a few times and didn't realize it!! Are you insane? I understand that there are risks in EMS, but taking UNNECESSARY risks is just plain stupidity. I also believe that you are mistaken about the results of the CPR machines. (I will look for concrete data) Not to mention it makes the stopping CPR to carry down stairs or just move the patient a thing of the past. The machine performs compressions better then ANY EMT/Medic, and the best part is it doesn't get tired. Each and every compression is the correct depth and at the correct rate.

Well said brother.

[x635 4,066]

Unless you can treat the underlying cause, or, in the rare case, witness it, there's little chance you're going to revive a cardiac arrest patient.

I see good things with the core cooling, and with the CPR machines to do effective compressions. Face it, it's nearly impossible to do effective compressions en route. And it's always a lot easier to backboard the patient anyways to secure the airway better and get more effective compressions.

The one hand thing is being promoted ONLY so the public does get whatever oxygenated blood flowing until others can get there, without the public having to be afraid they have to do mouth to mouth.

As for getting shocked during CPR, we're lucky that the manual paddles and conductive gel are a thing of the past.....

[FDNY 10-75 640]

And yet, devices are not improving outcomes.... and the real concern is that setting up devices may be taking time away from useful CPR. Energy seeks the path of least resistance, which is pad to pad. Locked hands, even on a bare chest, are unlikely to offer a better path to ground. General [ and perhaps unreasonable] fear of electricity should not be influencing patient care. If safety were the only issue, then find another line of work than EMS, which has many opportunities to be unsafe. What we are looking for as EMS providers is maximum effect with minimum risk. As the case becomes more compelling for continuous CPR, I'll ask again.... how long are we taking away from CPR to shock and is it necessary?

The Lucas/Lucas 2 does improve outcomes, look at the data...

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=15919574&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=15919574&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=12458066&ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17618034&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16159692&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

http://www.jolife.se/doc_en/Maule%20L%20assistance%20cardiaque%202007%20En%20Fr.pdf

http://www.jolife.se/doc_en/Gillis%20The%20use%20of%20LUCAS%202008%20p-ERC.pdf

http://www.jolife.se/doc_en/Durnez%20ROSC%20and%20neurological%202008%20p-ERC%20.pdf

http://www.ncbi.nlm.nih.gov/pubmed/18691783?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16221521&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16129539&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16129539&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=15797284&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

(Hopefully that's enough reading to convince you...)

Having used the device over a dozen times now, I can say with complete confidence that it rocks!

Also when you add ROSC (Code Cool), and an impedance threshold device (ResQPod), you really start to boost the potential for a good outcome.

Edited January 15, 2011 by FDNY 10-75

[ckroll 101]

The Lucas/Lucas 2 does improve outcomes, look at the data...

(Hopefully that's enough reading to convince you...)

Having used the device over a dozen times now, I can say with complete confidence that it rocks!

Also when you add ROSC (Code Cool), and an impedance threshold device (ResQPod), you really start to boost the potential for a good outcome.

From the journal Circulation as referenced in the 2010 AHA ACLS guidelines, Part 7 CPR techniques and devices.

"Over the past 25 years a variety of alternatives to conventional manual CPR have been developed in an effort to enhance perfusion during attempted resuscitation from cardiac arrest and to improve survival. Compared with conventional CPR, these techniques and devices typically require more personnel, training, and equipment, or they apply to a specific setting. Application of these devices has the potential to delay or interrupt CPR, so rescuers should be trained to minimize any interruption of chest compressions or defibrillation and should be retrained as needed. Efficacy for some techniques and devices has been reported in selected settings and patient conditions; however, no alternative technique or device in routine use has consistently been shown to be superior to conventional CPR for out-of-hospital basic life support."

[emphasis mine}

As for the rescue pod a.k.a. ITD the same section states":

" The ITD also has been used during conventional CPR with an endotracheal tube or with a face mask, if a tight seal is maintained.77,80,81 During conventional CPR with and without the ITD, 1 randomized trial80 reported no difference in overall survival; however, 1 prospective cohort study82 reported improved survival to emergency department (ED) admission with the use of the ITD. One meta-analysis of pooled data from both conventional CPR and ACD-CPR randomized trials83 demonstrated improved ROSC and short-term survival associated with the use of an ITD in the management of adult out-of-hospital cardiac arrest patients but no significant improvement in either survival to hospital discharge or neurologically intact survival to discharge."

[emphasis mine]

Thanks for the literature, here's back at you. I'm going to have to go with the AHA guidelines, however.

[ckroll 101]

On this point though, how do we address stairs and small elevators and other situations where it is near impossible to effectively perform compressions during patient movement? These situations take a whole lot more time than a shock.

The overarching concept seems to be early and absolutely uninterrupted chest compressions for the duration of the resuscitation attempt. Intubation, if it is to be performed at all comes later and with only a 10 second pause. All therapies are secondary to compressions and defibrillation. Blind airways that do not require a pause for insertion are given more weight in the new guidelines.

I think a patient that does not have ROSC prior to transfer to the ambulance is assumed to be beyond resuscitation. Primary skills/therapies have to be performed in situ if they are to be successful.

As for doing CPR through defibrillation...... It got you all talking about the new guidelines, now didn't it? If you were fish, you'd be dinner.

[helicopper 1,050]

The overarching concept seems to be early and absolutely uninterrupted chest compressions for the duration of the resuscitation attempt. Intubation, if it is to be performed at all comes later and with only a 10 second pause. All therapies are secondary to compressions and defibrillation. Blind airways that do not require a pause for insertion are given more weight in the new guidelines.

I think a patient that does not have ROSC prior to transfer to the ambulance is assumed to be beyond resuscitation. Primary skills/therapies have to be performed in situ if they are to be successful.

WIth this in mind (emphasis mine), how many systems (outside NYC) actually contact medical control for the cessation of resuscitation efforts and a field pronouncement these days?

[ckroll 101]

WIth this in mind (emphasis mine), how many systems (outside NYC) actually contact medical control for the cessation of resuscitation efforts and a field pronouncement these days?

Who does and who should may be different questions. Keeping this post within the context of AHA guidelines:

" A different rule may be useful when the additional diagnostic and therapeutic capabilities of an advanced life support EMS response are available to the victim. The National Association of EMS Physicians (NAEMSP) suggested that resuscitative efforts could be terminated in patients who do not respond to at least 20 minutes of ALS care.32

" An ALS termination of resuscitation rule was derived from a diverse population of rural and urban EMS settings.33 This rule recommends considering terminating resuscitation when ALL of the following criteria apply before moving to the ambulance for transport (see Figure 2): (1) arrest was not witnessed; (2) no bystander CPR was provided; (3) no ROSC after full ALS care in the field; and (4) no AED shocks were delivered. This rule has been retrospectively externally validated for adult patients in several regions in the US, Canada, and Europe,25,27–29 and it is reasonable to employ this rule in all ALS services (Class IIa,). "

[Guest TCA-ALS25]

Highlights of the 2010 American Heart Association

Guidelines for CPR and ECC

Click on link below

AHA Highlights for 2010

Thoughts?

Call me a geek, but I after 30+ years of doing this, I love reading various protocols fall by the wayside because we've either gotten better at (globally) diagnosing/treating heart disease or we've developed much better medications that ensure and maintain ROSC. The latest JEMS article on V-Fib confirms it.

[Guest TCA-ALS25]

The overarching concept seems to be early and absolutely uninterrupted chest compressions for the duration of the resuscitation attempt. Intubation, if it is to be performed at all comes later and with only a 10 second pause. All therapies are secondary to compressions and defibrillation. Blind airways that do not require a pause for insertion are given more weight in the new guidelines.

I think a patient that does not have ROSC prior to transfer to the ambulance is assumed to be beyond resuscitation. Primary skills/therapies have to be performed in situ if they are to be successful.

Hear! Hear! Probably sums up the 2010 ECC in a nutshell. BTW, King Tubes are a paramedic's best friend.

[ny10570 745]

Compressions during defibrillation is coming. In the lab latex, vinyl, nitril, etc were all effective at insulating against shock. Modern defibs result in little to no current traveling across the skin as long as pads are properly placed. As of now we're doing CPR during charging only stopping briefly to deliver the energy. In theory at least, as soon as people hear that charging tone they start backing away reflexively.

The Res q pod and other ITDs rapidly fell out of favor. In NYC we not only saw no improvement there was a small drop in ROSCs. I was told by one our docs that any real benefit is only realized with automated compressions and even then it's not as much as research initially suggested it would be.

I'm still not sold on automated compression devices. They're not very quick to deploy, require substantially CPR interruption to implement, and don't work on everyone. I'm a huge fan of the Phillips q CPR Puck. Real time visual feed back right on the patient's CHEST with rate, depth, and recoil. With it perfect CPR is very possible. As far as CPR during transport, if after 20 to 40 minutes of CPR the patient isn't back the future is bleek. Good quality CPR with minimal interruption early is more important.

Edited January 15, 2011 by ny10570

[x635 4,066]

I forgot to add, street medicine is an art, not a science...and cannot be succesful if reading from a "recipe card".

[ckroll 101]

Highlights of the 2010 American Heart Association

Guidelines for CPR and ECC

Click on link below

AHA Highlights for 2010

Thoughts?

For more information, see Circulation vol 122, issue 18, supp 3.

http://circ.ahajournals.org/ [The white and red box, right side of page.]

The long version is a must read for professional providers.

If I might respectfully rephrase what Seth says, I see paramedicine as craft built on science. At our best, we bring both in equal measure to the patient.

[x635 4,066]

Here is a video I took of the Physio Control LUCAS device in action at the Firehouse Central Expo in Dallas in September. It was attached to a LifePak 15 which it can be controlled and adjusted by (automatically).

[RWC130 594]

I just completed the 2010 Guidelines Science Update for

American Heart Association BLS Instructors

NOW READY TO TEACH NEW STUFF!

"Critical Skills" for AED

- Clears Victim to Analyze

- Clears Victim to Shock

[WAS967 97]

How does the Lucas interface with the LP15? Ie....what cabling does it use (or is wireless) and where does it attach/how does one control via the screen menus?