Since the American Heart Association's first set of CPR and Emergency Cardiac Care guidelines were published in 1974,1 we have all come to eagerly await the updates published every 5-6 years.
The new AHA Guidelines 20102 are now being avidly digested, dissected and debated, and EMS agencies across the country are reviewing and revising their cardiac arrest treatment protocols. As we do this, it's crucial to remember that these are guidelines, not mandates, and we must critically evaluate what specific protocols are optimal for our patients and our personnel.
THE DEVELOPMENT PROCESS
It is also important to recognize how the AHA's guidelines are developed. Most EMS personnel see only the material presented in BLS and ACLS courses, not the actual guidelines publication, worksheets, evidence rankings or journal articles. When EMS protocols do not match AHA course content completely, the result is often confusion and frustration. However, EMS medical directors must consider many factors as they adapt the guidelines to EMS use.
Development of each set of guidelines includes a staggering amount of work by hundreds of resuscitation experts from many organizations, not just the AHA. All available research articles are critiqued and ranked. Worksheets are posted for open comment as the new guidelines are debated. Eventually, an evidence-based consensus recommendation is published as "The Guidelines," where specific interventions are categorized as Class I (should be done), IIa (reasonable to do), IIb (may be considered) or Class III (not helpful and may be harmful). Some are "Class Indeterminate," where not enough research is available to recommend for or against that treatment.
Many answers are not clear-cut, so there are differences in guidelines published by the three main groups (AHA, International Liaison Committee on Resuscitation and European Resuscitation Council). Both medical and educational goals are considered. Overly complex guidelines are therefore avoided, while content and testing have been simplified to accommodate a broad base of learners. For example, we are taught to perform CPR in 2-minute cycles; therefore, the post-shock waiting time prior to a pulse check was set at 2 minutes in 2005 for ease of learning. Eventually, one ACLS course curriculum is created from the AHA Guidelines as a basic, evidence-based approach to cardiac arrest care for all healthcare providers.
Guidelines 2010 provide outstanding emphasis on several high-priority items for EMS to incorporate, such as:
- Simplification of public training and 9-1-1 instructions to focus on chest compressions only
- C-A-B approach, including "Push Hard, Push Fast" high-quality compressions with minimal interruptions
- Team approach to BLS and ACLS
- Waveform capnography peri-resuscitation
- Induced hypothermia after Return of Spontaneous Circulation (ROSC).
However, there are several potential stumbling blocks when translating the guidelines to EMS use. The AHA and authors of each set of guidelines are well aware of this, saying "It is important to note that these guidelines will not apply to all rescuers and all victims in all situations. The leader of a resuscitation attempt may need to adapt application of the guidelines to unique circumstances."3 They made a point of changing the title from "Standards" in 1974 to "Standards and Guidelines" and then to "Guidelines" as of 1992.4
Protocols Should Reflect Practice
New research may suggest a better approach long before the next guidelines are published; EMS can change faster. The "one-size-fits-all" ACLS course is not optimal. EM, ICU and EMS practitioners handle cardiac catastrophes daily and have considerably more education and experience than other ACLS learners, who might see one cardiac arrest every five years but are nonetheless required to complete ACLS courses. We can and should be expected to know more and do more. Treatments that are labeled as "not for routine use in cardiac arrest" in Guidelines 2010 may benefit specific situations, while some options listed in the guidelines may not be included in the ACLS course, so our EMS protocols may include them.