2010 AHA Guidelines on ECC and CPR

The American Heart Association (AHA) has recently updated the CPR and ECC Guidelines. You can access the full text pdf files of "AHA CPR and ECC Guidelines 2010" articles published in 18 October 2010 issue of Circulation by clicking here.

The most obvious and sensational change would probably be the change from the A-B-C to the C-A-B sequence of basic life support. In a way, I am not at all surprise of this change given the importance of chest compression ever since the last guidelines published in 2005. Numerous studies in recent years have shown the importance of chest compression, particularly for adult, non-traumatic, sudden onset of cardiac arrest, where the most probable etiology in most such cases would be myocardial infarction and its related arrhythmic sequelae of ventricular fibrillation, ventricular tachycardia, etc etc. In fact, over the last few years, we have seen a tremendous emphasis on chest compression so much so that AHA issued a scientific statement on Hands-Only CPR back in April 2008. At the same time, there is a de-emphasis on ventilation. Too much ventilation has the disadvantage of causing too much interruptions and impediment in our attempts in building up a good coronary perfusion pressure during chest compressions. Too much ventilation causes gastric distention as well, and increases risk of aspiration, reducing effectiveness of chest compression by splinting of diaphragm, In fact, too much ventilation is not necessary as the partial pressure of oxygen in the stagnated blood would have been enough to meet the minimal cellular metabolic demand in a cardiac arrest victim, especially during the first few minutes of arrest.



To me, the five major changes in Guidelines 2010 are:

1. The change from A-B-C sequence to C-A-B
- Beside minimizing delay, the C-A-B sequence also has the advantage over A-B-C because in A-B-C sequence, we are starting CPR with the steps which would be considered most repulsive for the public to initiate CPR (steps A and B). Thus, by using C-A-B sequence, we are encouraging public members to participate in CPR, enabling community empowerment and participation in this vital partnership of resuscitation.

Although no published human or animal evidence demonstrates that starting CPR with 30 compressions rather than 2 ventilations leads to improved outcome, chest compressions provide vital blood flow to the heart and brain, and studies of out-of-hospital adult cardiac arrest showed that survival was higher when bystanders made some attempt rather than no attempt to provide CPR.

2. Look, listen, feel is no longer recommended.
- “Look, listen, and feel for breathing” has been removed from the sequence for assessment of breathing after opening the airway. The healthcare provider briefly checks for breathing when checking responsiveness to detect signs of cardiac arrest. After delivery of 30 compressions, the lone rescuer opens the victim’s airway and delivers 2 breaths.

3. Atropine in cardiac arrest is out
Atropine is not recommended for routine use in the management of PEA/asystole and has been removed from the ACLS Cardiac Arrest Algorithm

4. Adenosine is in.
Adenosine is recommended in the initial diagnosis and treatment of stable, undifferentiated regular, monomorphic WCT

Note: adenosine should not be used for irregular WCTs because it may cause degeneration of the rhythm to VF.

5. Capnograph is in.
Capnography waveform can be used to check whether endotracheal intubation is successful or not, and secondly, it is used to monitor effectiveness of chest compression including achieving ROSC.

Other changes include:
Cricoid pressure
Cricoid pressure applied routinely is out.
Although it can prevent gastric aspiration, cricoid pressure may impede ventilation and interfere with placement of a supraglottic airway or intubation.

If cricoid pressure is used in special circumstances during cardiac arrest, the pressure should be adjusted, relaxed, or released if it impedes ventilation or advanced airway placement.

De-emphasis on pulse check
This guidelines minimizes the importance of pulse checks by healthcare providers. This is because detection of a pulse can be difficult, and even highly trained healthcare providers often incorrectly assess the presence or absence of a pulse when blood pressure is abnormally low or absent. Anyhow, chest compressions delivered to patients subsequently found not to be in cardiac arrest rarely lead to significant injury