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- Discuss the key changes to the chain of life and cardiopulmonary resuscitation
- Explain the rationale for prioritizing chest compressions in C-A-B
- Identify the updates to advanced life support interventions during cardiac arrest
- Introduce the importance of and priorities in post-arrest patient management
Every five years, the American Heart Association (AHA) convenes with the world's leading authorities on cardiac care to evaluate the most current research studies and ideas and update its guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC). The 2010 update to CPR and ECC, which marked the 50th anniversary of updates to modern CPR, is arguably the most thoroughly researched to date, with important and dynamic changes for how EMS provides care. Because nearly 175,000 out-of-hospital cardiac arrests occur in the U.S. annually,it is important for all EMS providers to be up to date with the most current practices.1 This month's article highlights the changes that impact EMS care the most.
Science is not always precise, even though we would like it to be. And it is not always clear when research is evaluated how beneficial different medications and interventions may actually be. To help users understand these recommendations, there are four different classes, each identified with the level of evidence supporting it. Table 1 highlights the different classes of recommendations, ranging from class I to III. In a change from the 2000 recommendations, the "class indeterminate" recommendation level that was used when there was no evidence for or against a drug's use has been eliminated. Every recommendation in this year's guidelines is supported with its respective level of evidence (LOE) and is graded A through C (Table 2).
Chain of Survival
The chain of survival has been a staple of CPR courses and EMS programs for years. With the new addition of the fifth link in the chain--comprehensive post-cardiac arrest care--EMS's role in delivering patients to hospitals that can appropriately manage their care becomes even more important. Researchers believe that accurate use of all five links in the chain of survival can boost cardiac arrest survival to nearly 50%.1
Each link in the chain builds on proper utilization of the previous link. For example, quality early CPR cannot happen without early recognition; good BLS care is the foundation of post-cardiac survival.3 In an effort to support early CPR, the AHA has established a class I (LOE B) recommendation that all emergency medical dispatchers (EMDs) be trained to recognize pre-cardiac arrest symptoms, including agonal breathing, and coach laypersons to perform chest compressions immediately without a pulse check.3 It is preferred and easier to coach chest compressions only rather than traditional CPR. Considering the low frequency of serious injury from chest compressions on patients not in cardiac arrest, the benefits far outweigh any risks of unnecessary chest compressions.
The sequence of CPR has taken a dramatic change. Since we now know that even the best chest compressions result in a cardiac output roughly 20% of normal, it is essential to appreciate the lifesaving importance of beginning chest compressions as early as possible and maintaining them without interruption throughout resuscitation. To promote this, there has been a switch from the long-used ABC algorithm to CAB: circulation, airway and then breathing. Laypersons will no longer be taught pulse checks in their CPR and first aid courses; instead, they will be instructed to immediately begin chest compressions on patients who are unresponsive with abnormal or no breathing.3 When a caller is not trained in CPR, 9-1-1 dispatchers should instruct the person in how to perform chest compressions. The AHA hopes that EMS crews will begin to see CPR being performed more often upon their arrival; however, EMS crews will need to accurately and quickly assess the patient to determine their true status. Expect some patients receiving CPR to have a pulse. When evaluating these patients, limit pulse checks to less than 10 seconds; continue chest compressions, unless there is no doubt the patient has a strong pulse.3