On 18th of October European Resuscitation Council (ERC) implemented the newest version of European Guidelines on Resuscitation. Comparison with the last version suggests that it is rather an evolution than revolution. In this brief summary I am going to present the main points of European Guidelines on Resuscitation 2010.,
In 2010 Guidelines basic recommendations connected with adult basic life support (BLS) remain unchanged, but there are some modifications. As in 2005, trained rescuers should provide CPR with ratio of compressions and ventilations 30:2, while for untrained rescuers telephone-guided CPR without ventilations (only chest compressions) is suggested. A great emphasis is placed on the early start and correct, uninterrupted chest compressions, which means pushing the chest to a depth of 5 cm at a rate of at least 100 compressions per minute.
In situations in which electrical therapies are needed, the earlier algorithm of 2-3 minutes CPR before heart rate assessment and beginning of defibrillation is no longer recommended, because the new guidelines accentuate the importance of minimizing any pauses during resuscitation. Therefore chest compressions should follow defibrillation as quick as possible, what is more – they should be continued during defibrillator charging and the interruption in chest compressions before delivering a defibrillation should last no longer than 5 s. In some special cases, such as VF/VT occurs during cardiac catheterization or in the early post-operative period following cardiac surgery or when the patient is connected to the manual defibrillator, a strategy of three shocks one by one may be considered. Any electrode pastes and gels should not be used, because they can induce electrical potential.
The role of correct chest compressions is emphasized also in Advanced Life Support (ALS) Guidelines, which suggest that compressions should be interrupted only to carry out some specific medical interventions. Very significant are also watchful waiting and the ability to notice warning signs connected with potential risk of sudden cardiac death out of hospital in combination with “track and trigger” system to prevent in-hospital cardiac arrest. Pre-cordial thump is not as important as it was according to Guidelines from 2005, likewise early tracheal intubation, unless rescuers are highly skilled and it will not disrupt chest compressions for longer that it is needed.
What is new about medicines? Delivery of drugs via trachea is no longer recommended; if it is only possible, drugs should be administered intravenously or by the intraosseous route. During VF/VT treatment, 1 mg of adrenaline is given after the third shock, as well as amiodarone 300mg, but in contrast to amiodarone, is continued every 3-5 minutes. Atropine should not be used in asystole or pulseless electrical activity.
Capnography is regarded as a very good way to monitor tracheal tube placement, quality of CPR and to indicate return of spontaneous circulation (ROSC). The great attention is paid to the potential harm caused by hyperoxaemia after ROSC and that is the reason to titrate oxygen to achieve a Sa 94-98% after ROSC. The importance of post-cardiac arrest syndrome treatment is also emphasized.
In patients after cardiac arrest, blood glucose level above 180 mg/dl has to be treated, but hypoglycaemia must be avoided. Also, as a way of treatment, therapeutic hypothermia (32 – 34°C for 12-24 hours) in patients with coma after cardiac arrest with shockable or non-shockable rythms should be used.
Children are special patients, and the Pediatric Life Support Guidelines are special too. For most of healthcare providers it is impossible to recognize the presence or absence of pulse in children or infants in less than 10 s. Therefore, if rescuers suspect cardiac arrest, they should begin CPR in time less than 10 s. A highly skilled rescuer can check pulse according to the age of the child: on carotid (children), brachial (infants) or femoral (children and infants) artery.
The compression–ventilation ratio depends on the number and the skills of rescuers. Lay rescuers should use 30:2 ratio, whereas healthcare professionals should rather practice 15:2 ratio. However, if they are alone or there are some difficulties with adequate number of chest compressions, they can use 30:2 ratio.
The technique of compressions also depends on the number of the rescuers and on the age of a child. CPR for infants can be made by two-finger compression for single rescuer or two-thumb encircling technique for more than one rescuer. For older children the rescuer can choose one- or two-hand technique. The depth of the compressions should amount to at least 1/3 of the anterior-posterior diameter of the chest for each child with compression rate at least 100 per minute, but no more than 120 per minute. It is very important to release completely the chest between the compressions.
AED is useful for children older than one year. Nowadays some manufacturers produce equipment with special pediatric pads or software with the energy 50-75 J, which is recommended for children from one to eight years old. If a child is younger than one year, risk/benefit ratio should be considered before using an AED. Using manual defibrillator, healthcare providers should not forget to continue chest compressions even during applying and charging the paddles or self-adhesive pads (if the chest of a child is big enough) to minimize the no-flow time. In children VF/VT defibrillation non-escalating dose of 4 J per kg in single shock strategy should be used.
Cuffed tracheal tubes in appropriate size can be used in infants and children. The safety of circoid pressure is not clear, therefore if it causes difficulties in intubation or ventilation, the rescuer can withdraw from it. Likewise in ALS, capnography is recommended as a best way to monitor the position of tracheal tube and CPR quality and the importance of rapid response systems in reducing in-hospital mortality is emphasized.
Totally new problems signalized in 2010 Guidelines are proceedings in channelopathies, traumas, single ventricle pre- and post-1st stage repair, post-Fontan circulation, and pulmonary hypertension.
Separate chapter is devoted to the resuscitation of babies at birth. Main points, such as CPR ratio, remain unchanged. In the newest recommendations cord clamping should be made at least 1 minute after the complete delivery of an infant. For term infants the best gas for resuscitation is air, whereas for preterm babies (less than 32 week of gestation) blended oxygen and air is preferred. Using therapeutic hypothermia in term or near-term infants with tendency to severe hypoxic-ischemic encephalopathy is significant in post-resuscitation care.
To sum up, the main points in new Resuscitation Guidelines are early and deep enough compressions of the chest, early defibrillation and therapeutic hypothermia after cardiac arrest.
Not only medical algorithms and suggestions, but also educational recommendations are contained in 2010 Guidelines. It is very important to train all people in BLS, because proper CPR performed by a witness of an accident increases the prospect of survival even two-three times. Unfortunately, too many citizens still do not decide to undertake cardiopulmonary resuscitation.
I hope, it will change before the next European Resuscitation Guidelines is published.