They have arrived! October 1st, 2015 at exactly 12:01am the Emergency Cardiac Care Guidelines for 2015 were released in the Journal of Circulation. Because they are shrouded in such secrecy, they are always met with much anticipation. So, I say bleary eyed staring into the computer screen, hitting the refresh button repeatedly waiting with anxious anticipation for them to magically appear on my screen. When they did, I was somewhat underwhelmed. While there are tweaks to the delivery of Basic Life Support, Advanced Cardiac Life Support, Pediatric Advanced Life Support and First Aid, there are no major clinical breakthroughs to report nor major changes in the care we deliver. The following is a summary of only the changes. It does not include all treatment recommendations that remain intact but are unchanged. This is an attempt to summarize the changes that will have the most impact and so does not include the scientific references or the in-depth explanations. Our new courses will include those. We expect the to be released in the new future.
This document focuses on the updates that affect care for adults. To stay up-to-date with other breaking releases please enter your email address on the bottom of this page.
Because the requirements and the availability of care differs significantly between cardiac arrest that occurs in the hospital and cardiac arrest outside of the hospital two different chains of command have been developed. The Inhospital Cardiac (IHCA) Arrest Chain includes;
Surveillance and Prevention
Recognition and activation of the emergency response system
Immediate high quality CPR
Advanced life support and postarrest care
Recognition and activation of the emergency response system
Immediate high quality CPR
Basic and advanced emergency medical services
Advanced life support
The use of Rapid Response Teams (RRT) or Medical Emergency Teams (MET) to respond to deteriorating patients on general care wards for both adult and children hospitals is encouraged. Although they were in their infancy when the 2010 Guidelines were released, there is now good scientific data to support their use to reduce the incidence of IHCA.
Dispatcher recognition of cardiac arrest
EMS Dispatchers should be trained to inquire about agonal or absent respirations in all unresponsive patients
The assumption should be made that the patient is in cardiac arrest in the absence of consciousness and abnormal or absent breathing
Training should include the fact that brief seizure activity may be the first sign of cardiac arrest and should be recognized as such
All EMS Dispatchers should be prepared to “talk the caller through the steps of CPR.”
Studies are being done to investigate the possible impact of utilizing social media to notify nearby potential rescuers to respond. This has been done in a limited way in a number of communities with success.
Lay rescuers are being encouraged to utilize their cell phone for 911 calls. When the dispatcher answers they are encouraged to put their cell phone on speaker, put it down and begin compressions while speaking with the dispatcher.
All laypersons should delivery Hands Only CPR at a minimum. If they are trained and comfortable they may add ventilation at a ratio of 30:2
The rate of compressions has been increased from “at least 100” to between 100-120 compressions per minute.
Emphasize the importance of minimizing interruptions in order to maintain a high “compression fraction”
Compression fraction is the percentage of time compared to total time that compressions are actually being done. The minimum goal should be 60%
Depth – should be at least 2 inches but no more than 2.4 inches. The most common error found was compressions that were too shallow. There was one small study that documented in increase in non life threatening injuries when compressions were done too deeply
The main changes are in the way the patient is approached. The guidelines emphasize the ability to complete multiple steps simultaneous. For example, the rescuer is encouraged to check for normal breathing and a pulse at the same time rather than chronologically.
There is greater flexibility in notification of the emergency response system to allow for the differences in environments of care.
There is also flexibility for the healthcare provider to tailor their response to the potential cause of arrest.
The emphasis is once again being placed on continuous compressions. The goal is a compression fraction of at least 60%.
The compression rate has been increased to 100-120 per minute.
Because the greatest emphasis is placed on a diastolic pressure (that’s when the arteries of the heart are filled) care must be taken not to lean on the chest wall preventing it from fully recoiling between compressions.
The recommended depth is unchanged. It is 2 inches, however an upper limit has been added. It is 2.4 inches. In a relatively small study some non life threatening injuries were caused by compressions that were too deep. Most errors in the deliver of compressions occurred when they were too shallow, not too deep.
AHA has accepted the application of passive ventilation and continuous chest compressions in groups of 200 as adopted by many EMS models.
If an advanced airway is in placed the ventilation rate has been changed from a range of 8-10 per minute to 10 a minute mainly to make it easier to teach.
The debate over Shock first vs CPR first has been clarified. If a defibrillator or AED is immediately available it should be used. If it is not immediately available compressions should be performed until it is available. It should be utilized immediate after it arrives on scene.
Feedback devices (including audiovisual prompting) have shown to be helpful in increasing the efficacy of CPR in a healthcare environment and are encouraged. However there was no correlation between the use of compression devices and survival rates. The routine device of automated compression devices is not recommended. It may be reasonable to utilize a compression device in areas where high quality compressions are hard to delivery such as angiography suites or moving ambulances.
Delayed Ventilation is acceptable in EMS systems who have a bundled response to cardiac arrest including up to 3 cycles of 200 continuous compressions with interposed shocks before active ventilation. Three studies of both urban and suburban systems have shown increased survival rates when this system was trained and used consistently within the system.
The routine use of impedance threshold devices (ITD) during CPR is not recommended.
If the cause of arrest is known and considered reversible, the use of extracorporeal techniques and invasive perfusion devices may be useful. The use of these devices routinely is not recommended.
The combined use of Vasopressin with Epinephrine showed now advantage over the use of Epinephrine alone. Therefore for the purpose of ease of teaching and limiting the number of pharmacological agents Vasopressin has been removed from the cardiac arrest algorithm in the 2015 Guidelines.
End Tital C02 that remains low (less than 10mm) despite resuscitation is associated with a very low successful resuscitation rate. Therefore when used in conjunction with other indicators, a low end tidal C02 after 20 minutes of resuscitation may help determine when to stop resuscitation.
There was an association of the administration of Epinephrine earlier in arrest when treating a nonshockable rhythm with increased neuro intact discharge. Ideally it should be administered within 1-3 minutes of arrest.
Post cardiac arrest there is no evidence to support the use of Lidocaine infusion. However, there were no negative outcomes and therefore it is acceptable to consider its’ use.
Beta Blockade Post Arrest – although there is no evidence to support the use of beta blockade in the immediate post arrest period, it is acceptable practice to consider its use. Each patient should be evaluated individually as in some studies the use of Beta Blockers post arrest were associated with hemodynamic instability.
Post Cardiac Arrest Care – this is an area of great emphasis in the new Guidelines as our goal is no longer return of spontaneous circulation but neuro intact survival. Neuro intact survival depends a lot on the level of care received in the immediate post arrest phase of care.
Recommended emergently following cardiac arrest in the adult patient. It should not be delayed until the patient is stabilized or rewarmed. It should be done immediately upon return of spontaneous circulation. The vast majority of cardiac arrest are ischemic in nature. Angiography should be done whether or not the patient regains consciousness immediately post arrest. The ramifications of leaving the vessel closed until a patient regains consciousness or if they regain consciousness is a very costly decision.
All adult patients without meaningful response to stimuli following cardiac arrest should have Targeted Temperature Management (TTM). Targeted temperature for these patients is 32-36 degrees C and should be maintained for at least 24 hours.
Fever should be actively prevented following TTM.
The routine use of prehospital cooling for patients using infusions of cold IV fluids is not recommended. There was no documented advantage and potential complications were identified.
The goal blood pressure following cardiac arrest remains 90mmHg systolic or a mean arterial pressure of 65mmHG.
Determination of poor clinical outcome potential cannot be determine sooner than 72 hours after arrest in patients who have not been cooled. In patient who have been cooled this must be extended to 72 hours after the patient has returned to normal temperature. This can also be elongated by the use of sedation or paralysis in the immediate post arrest treatment phase.
All patients who progress to brain death following resuscitation should be considered potential organ donors. Patients who do not achieve ROSC should be considered for kidney and/or liver donations if a rapid recovery program exists in the area.
Acute Coronary Syndromes
Trained Non-physicians are capable of obtaining and interpreting EKGs in the prehospital setting for evidence of ST elevation MI (STEMI) and it should be a routine occurrence in EMS.
Direct transport to a facility capable of Percutanous Coronary Intervention is the preferred method of care for patients diagnosed in the field with STEMI.
Patients who receive fibrinolysis in hospitals not capable of PCI should be transported for angiography within 3-4 hours of administration.
Troponin alone should not be used to determine low risk and discharge. Troponin in conjunction with risk stratification must be utilized.
Complications of routine oxygen therapy have been well documented. Oxygen therapy should be withheld from acute coronary syndrome patients with normal oxygen saturations. (94-99%)
Special Resuscitation Situations
Narcan – it is reasonable to administer Narcan to the patient who has abnormal breathing but a pulse who is at risk of opiod overdose. This training should have a first aid base rather than a healthcare provider base. Resuscitation should not be delayed while waiting for Narcan to work.
In pulseless patients it may be reasonable to administer Narcan based on the fact that they may be in respiratory arrest with a very weak and possible not detectable pulse. If pulseless arrest is definitive (i.e. obvious arrest, arterial monitoring) Narcan should not be administered and resuscitation should be performed according to the cardiac arrest algorithm.
Pregnancy – the priorities of resuscitation are high quality CPR for the mother and relieving aortocaval compression. If the fundus height is at or above the umbilicus, manual left uterine displacement can be beneficial during compressions.