Bob Elling, MPA, EMT-P
(Part 2 of a 6-part series: CPR, ECC, and First Aid Guidelines: Version 2015)
A number of topics were addressed in the 2015 Guidelines on systems of care and continuous quality improvement (CQI) that will be incorporated into updated protocols and procedures. This section is extremely important, as those communities that take the time to focus on improving all the links in the chain of survival will see the greatest improvements in survival. Whose responsibility is this? All of us have a responsibility as first aiders, EMS providers, health care professionals, and interested members of the public to step up and help implement all sections of the Guidelines!
Let’s take a closer look at the specifics here.
- It is recommended that PAD programs for patients with OHCA be implemented in communities at risk for cardiac arrest (Class I).
Dispatcher Recognition of Cardiac Arrest
- It is recommended that emergency dispatchers determine if a patient is unconscious with abnormal breathing after acquiring the requisite information to determine the location of the event (Class I).
- If the patient is unconscious with abnormal or absent breathing, it is reasonable for the emergency dispatcher to assume that the patient is in cardiac arrest (Class IIa).
- Dispatchers should be educated to identify unconsciousness with abnormal and agonal gasps across a range of clinical presentations and descriptions (Class I).
- We recommend that dispatchers provide chest compression-only CPR instructions to callers for adults with suspected OHCA (Class I).
Use of Social Media to Summon Rescuers
- Given the low risk of harm and the potential benefit of such notifications, it may be reasonable for communities to incorporate, where available, social media technologies that summon rescuers who are willing and able to perform CPR and are in close proximity to a suspected victim of OHCA (Class IIb).
Transport to Specialized Cardiac Arrest Centers
- A regionalized approach to OHCA resuscitation that includes the use of cardiac resuscitation centers may be considered (Class IIb).
Immediate Recognition and Activation of the Emergency Response System
- It is recommended that emergency dispatchers determine if a patient is unresponsive with abnormal breathing after acquiring the requisite information to determine the location of the event (Class I).
- If the patient is unresponsive with abnormal or absent breathing, it is reasonable for the emergency dispatcher to assume that the patient is in cardiac arrest (Class IIa).
- Dispatchers should be educated to identify unresponsiveness with abnormal breathing and agonal gasps across a range of clinical presentations and descriptions (Class I).
Untrained Lay Rescuer
- Untrained lay rescuers should provide compression-only CPR, with or without dispatcher assistance (Class I).
- The rescuer should continue compression-only CPR until the arrival of an AED or rescuers with additional training (Class I).
Trained Lay Rescuer
- All lay rescuers should, at a minimum, provide chest compressions for victims of cardiac arrest (Class I). In addition, if the trained lay rescuer is able to perform rescue breaths, he or she should add rescue breaths at a ratio of 30 compressions to 2 breaths.
- The rescuer should continue CPR until an AED arrives and is ready for use or until EMS providers take over care of the victim (Class I).
Health Care Provider
- It is reasonable for health care providers to provide chest compressions and ventilation for all adult patients in cardiac arrest, from either a cardiac or noncardiac cause (Class IIa).
- For witnessed OHCA with a shockable rhythm, it may be reasonable for EMS systems with priority-based, multitiered response to delay positive-pressure ventilation by using a strategy of up to 3 cycles of 200 continuous compressions with passive oxygen insufflation and airway adjuncts (Class IIb).
Recognition of Arrest
- Dispatchers should instruct rescuers to provide CPR if the victim is unresponsive with no normal breathing, even when the victim demonstrates occasional gasps (Class I).
Suspected Opioid-Related Life-Threatening Emergency
- For a patient with known or suspected opioid overdose who has a definite pulse but no normal breathing or only gasping (ie, a respiratory arrest), in addition to providing standard BLS care, it is reasonable for appropriately trained BLS health care providers to administer intramuscular or intranasal naloxone (Class IIa).
- For patients in cardiac arrest, medication administration is ineffective without concomitant chest compressions to ensure drug delivery to the tissues. Thus naloxone administration may be considered after initiation of CPR if there is high suspicion for opioid overdose (Class IIb).
- It is reasonable to provide opioid overdose response education with or without naloxone distribution to persons at risk for opioid overdose in any setting (Class IIa).
Chest Compression Rate
- In adult victims of cardiac arrest, it is reasonable for rescuers to perform chest compressions at a rate of 100 to 120 compressions per minute (Class IIa).
Chest Compression Depth
- During manual CPR, rescuers should perform chest compressions to a depth of at least 2 inches (5 cm) for an average adult, while avoiding excessive chest compression depths (greater than 2.4 inches [6 cm]) (Class I).
Chest Wall Recoil
- It is reasonable for rescuers to avoid leaning on the chest between compressions to allow full chest wall recoil for adults in cardiac arrest (Class IIa).
Minimizing Interruptions in Chest Compressions
- In adult cardiac arrest, total preshock and postshock pauses in chest compressions should be as short as possible (Class I).
- For adults in cardiac arrest receiving CPR without an advanced airway, it is reasonable to pause compressions for less than 10 seconds to deliver 2 breaths (Class IIa).
- In adult cardiac arrest with an unprotected airway, it may be reasonable to perform CPR with the goal of keeping the chest compression fraction as high as possible, with a target of at least 60% (Class IIb).
Layperson: Compression-Only CPR Versus Conventional CPR
- Dispatchers should instruct untrained lay rescuers to provide compression-only CPR for adults with sudden cardiac arrest (Class I).
- Compression-only CPR is a reasonable alternative to conventional CPR in the adult cardiac arrest patient (Class IIa).
- For trained rescuers, ventilation may be considered in addition to chest compressions for the adult in cardiac arrest (Class IIb).
Open the Airway: Lay Rescuer
- For victims with suspected spinal injury, rescuers should initially use manual spinal motion restriction (eg, placing a hand on either side of the patient’s head to hold it still) rather than immobilization devices, because use of immobilization devices by lay rescuers may be harmful (Class III).
- As long as the patient does not have an advanced airway in place, rescuers should deliver cycles of 30 compressions and 2 breaths during CPR. The rescuer delivers breaths during pauses in compressions and delivers each breath over approximately 1 second (Class IIa).
Ventilation With an Advanced Airway
- When the victim has an advanced airway in place during CPR, rescuers no longer need to deliver cycles of 30 compressions and 2 breaths (ie, they no longer need to interrupt compressions to deliver 2 breaths). Instead, it may be reasonable for the provider to deliver 1 breath every 6 seconds (10 breaths per minute) while continuous chest compressions are being performed (Class IIb).
Passive Oxygen Versus Positive-Pressure Oxygen During CPR
- We do not recommend the routine use of passive ventilation techniques during conventional CPR for adults, because the usefulness/effectiveness of these techniques is unknown (Class IIb).
- In EMS systems that use bundles of care involving continuous chest compressions, the use of passive ventilation techniques may be considered as part of that bundle (Class IIb).
CPR Before Defibrillation
- For witnessed adult cardiac arrest when an AED is immediately available, it is reasonable that the defibrillator be used as soon as possible (Class IIa).
- For adults with unmonitored cardiac arrest or for whom an AED is not immediately available, it is reasonable that CPR be initiated while the defibrillator equipment is being retrieved and applied, and that defibrillation, if indicated, be attempted as soon as the device is ready for use (Class IIa).
Analysis of Rhythm During Compressions
- There is insufficient evidence to recommend the use of artifact-filtering algorithms for analysis of ECG rhythm during CPR. Their use may be considered as part of a research program of if an EMS system has already incorporated ECG artifact-filtering algorithms in its resuscitation protocols (Class IIb).
Timing of Rhythm Check
- It may be reasonable to immediately resume chest compressions after shock delivery for adults in cardiac arrest in any setting (Class IIb).
Chest Compression Feedback
- It may be reasonable to use audiovisual feedback devices during CPR for real-time optimization of CPR performance (Class IIb).
The next section of this blog will address specifics in the area of adult advanced cardiovascular life support and ACS. If you want to read all the details and background, take a look at the Supplement to Circulation, volume 132, number 18, supplement 2, November 3, 2015.
See you in the streets!