Highlights of the 2010 Guidelines for CPR and ECC - ECC Guidelines

c p r t e c h n i q u e s a n d d e v i c e s
2005 (Old): There was insufficient evidence to recommend a
biphasic dose for cardioversion of monomorphic VT. The 2005
AHA Guidelines for CPR and ECC recommended use of an
unsynchronized shock for treatment of the unstable patient
with polymorphic VT.
Why: The writing group agreed that it would be helpful to add
a biphasic dose recommendation to the 2010 AHA Guidelines
for CPR and ECC for cardioversion of monomorphic VT but
wanted to emphasize the need to treat polymorphic VT as
unstable and as an arrest rhythm.
Fibrillation Waveform Analysis to
Predict Outcome
2010 (No Change From 2005): The value of VF waveform
analysis to guide defibrillation management during resuscitation
is uncertain.
Pacing
2010 (No Change From 2005): Pacing is not routinely
recommended for patients in asystolic cardiac arrest. In
patients with symptomatic bradycardia with a pulse, it is
reasonable for healthcare providers to be prepared to initiate
transcutaneous pacing in patients who do not respond to
drugs. If transcutaneous pacing fails, transvenous pacing
initiated by a trained provider with experience in central
venous access and intracardiac pacing is probably indicated.
CPR TECHNIQUES AND DEVICES
Summary of Key Issues and Major Changes
To date, no CPR device has consistently been shown to be
superior to standard conventional (manual) CPR for out-ofhospital
BLS, and no device other than a defibrillator has
consistently improved long-term survival from out-of-hospital
cardiac arrest. This part of the 2010 AHA Guidelines for CPR
and ECC does contain summaries of recent clinical trials.
CPR Techniques
Alternatives to conventional manual CPR have been
developed in an effort to enhance perfusion during
resuscitation from cardiac arrest and to improve survival.
Compared with conventional CPR, these techniques typically
require more personnel, training, and equipment, or they
apply to a specific setting. Some alternative CPR techniques
may improve hemodynamics or short-term survival when
used by well-trained providers in selected patients.
2010 (New): The precordial thump should not be used for
unwitnessed out-of-hospital cardiac arrest. The precordial
thump may be considered for patients with witnessed,
monitored, unstable VT (including pulseless VT) if a defibrillator
is not immediately ready for use, but it should not delay CPR
and shock delivery.
2005 (Old): No recommendation was provided previously.
Why: A precordial thump has been reported to convert
ventricular tachyarrhythmias in some studies. However,
2 larger case series found that the precordial thump did
not result in ROSC for cases of VF. Reported complications
associated with precordial thump include sternal fracture,
osteomyelitis, stroke, and triggering of malignant arrhythmias
in adults and children. The precordial thump should not delay
initiation of CPR or defibrillation.
CPR Devices
Several mechanical CPR devices have been the focus of
recent clinical trials. Initiation of therapy with these devices (ie,
application and positioning of the device) has the potential
to delay or interrupt CPR for the victim of cardiac arrest, so
rescuers should be trained to minimize any interruption of
chest compressions or defibrillation and should be retrained
as needed.
Use of the impedance threshold device improved ROSC
and short-term survival in adults with out-of-hospital cardiac
arrest, but it has not improved long-term survival in patients
with cardiac arrest.
One multicenter, prospective, randomized controlled trial
comparing load-distributing band CPR (AutoPulse ® ) with
manual CPR for out-of-hospital cardiac arrest demonstrated
no improvement in 4-hour survival and worse neurologic
outcome when the device was used. Further studies are
required to determine if site-specific factors and experience
with deployment of the device could influence its efficacy.
There is insufficient evidence to support the routine use of
this device.
Case series employing mechanical piston devices have
reported variable degrees of success. Such devices may be
considered for use when conventional CPR would be difficult
to maintain (eg, during diagnostic studies).
To prevent delays and maximize efficiency, initial training,
ongoing monitoring, and retraining programs should be
offered on a frequent basis to providers using CPR devices.
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