Most of you will be aware of and have probably read by now, the updated ILCOR resuscitation guidelines that came out last year. The Australian Resuscitation Council has joined together with the New Zealand Resuscitation Council and they have issued joint guidelines for ANZ practice. Below is a summary of the BLS and ALS components of those guidelines.
There are also good reviews of the updated guidelines available at:
The Australian Resuscitation Council, http://www.resus.org.au/
Scott Weingart’s EM Crit – http://emcrit.org/podcasts/acls-guidelines-2010/
Emergency Medicine Australia Vol. 23, No 3, June 2011 – Available from your local friendly Australian ED physician or your library
Summary of updated ILCOR 2010 resuscitation guidelines
BLS
Algorithm = D.R.S.A.B.C.D.
- Check for Danger
- Check Response ? The trigger to initiate BLS is now “not responsive and absent or abnormal breathing” rather than “no signs of life”.
- Send for help.
- Open and clear Airway
- Rescue Breath x 2. However, compression-only resuscitation is preferable to no resuscitation at all and is advocated when advising a BLS provider over the phone.
- Chest Compression at the midpoint of the sternum, to a depth of 5cm or one third the depth of the chest, at a rate of 100bpm and a compression to ventilation ratio of 30:2 for everyone except neonates. Interruptions to effective chest compressions should be minimised and the rescuer applying the compressions should be rotated every 2 minutes in order to maintain efficacy.
- Defibrilation via AED (BLS providers. ALS providers procede to the ALS pathway, but should use the AED if that is all that is available)
ALS
Initiate BLS as above.
Shockable rythmns (VF and pulseless VT)
- The first defibrilation should be administered as soon as the defibrilator is attached to the patient and charged to 200J biphasic, with due caution for the rescuers. CPR should only be interrupted in order to deliver a safe defibrilation dose; ie chest compressions should be continued during charging.
- Immediately resume CPR for 2 minutes
- Check rythmn and for ROSC. It is reasonable to pre-emptively charge to 200J just prior to this in order that defibrilation can be administered without delay, if appropriate. If not required the charge can be dumped back into the machine by turning the dial back to “Monitor”.
- Defibrilate 200J biphasic
- Immediately resume CPR for 2 minutes and give Adrenalin 1mg IV or IO. Subsequent adrenalin doses are then given every second cycle of CPR.
- Check rythmn and for ROSC
- Defibrilate 200J biphasic
- Immediately resume CPR for 2 minutes and give Amiodarone 300mg IV or IO.
- Check rythmn and for ROSC
- Go back to step 5
Additional notes
A three-stack shock can be delivered for a witnessed, monitored VF/VT arrest where the pads are already in place or can be placed within 10seconds of the arrest. Otherwise a single shock only is advised.
A precordial thump is still considered acceptable for a witnessed, monitored arrest.
Non-shockable rythmns
Cycle 2 minute periods of CPR and assessment of rythmn and ROSC, with adrenalin 1mg IV/IO every second cycle. There is no role for atropine unless the cause of the arrest is a witnessed vagal stimulus.
Other items
- Intubation is not required, but where performed, should result in a minimal interruption to chest compression. An LMA is an acceptable alternative. Once in place capnography should be used as the waveform and number aid confirmation of tube placement, efficacy of CPR and identification of return of ROSC.
- Once intubation is completed, ALS rescuers may choose to provide a compression to ventilation ratio of 15:1, but 30:2 is fine too.
- Identification and treatment of the 4H4T reversible causes of arrest is encouraged
- Bicarbonate and MgSO4 have accepted, though largely unproven, roles in specific circumstances
- The IV route is preferred. The IO route is the preferable alternative and all resuscitation drugs can be given this way. The ETT route is less preferable, unless it is the only one available (Adrenalin, lignocaine and atropine only).
Post resuscitation care
Care following successful resuscitation should be protocolised and include:
- Oxygen supplementation, aiming for SpO2 of 95-98% – Evidence suggests hyperoxia post resuscitation results in a worse neurological outcome.
- Preserve euvolaemia and normotension
- Preserve cerebral perfusion
- Maintain euglycaemia (BSL 6 – 10mmol/L)
- If the patient remains unresponsive despite ROSC then initiate cerebroprotection with therapeutic mild hypothermia (T 32 -34C) for 12 -24 hours (Class A, Level I for out of hospital VF. Class B, Level III for non-shockable OHCA or in-hospital cardiac arrest of any rythmn). Cooling methods include ice packs, 30ml/kg of 0.9%saline or Ringer’s Lactate at 4C, cooling blankets, or intravascular cooling devices.
- Primary PCI after sustained ROSC immediately following a primary cardiac arrest is advocated, regardless of the ECG appearance (Class A, Level III), even if hypothermic cerebroprotection has been commenced (Class B, Level III)
(All Class A recommendations, with Level III evidence, unless otherwise stated)
Post resuscitation prognostication
Without therapeutic hypothermia
Prediction of outcome within 24 hours of ROSC is unreliable
- Clinical parameters: Absent pupilary light response and absent corneal reflex after 72hours reliably predict a poor outcome. Absent vestibulo-occular reflexes after 24 hours and a motor GCS of 2 or less after 72 hours are less reliable and the presence of myoclonic activity is no longer a recommended indicator.
- Biomarkers (NSE, S100b protein, soluble P-selectin) are not reliable enough of themselves
- Median nerve N20 SSEP between 24 – 72 hours is a reliable predictor of poor outcome, with a false poitive rate of < 1%.
- Unprocessed EEG showing generalised suppression
Prognosis following therapeutic hypothermia
- Less reliable due to the paucity of evidence
- Accepted reliable indicators of a poor neurological outcome include absent pupillary light response and absent corneal reflex after 72hours, absent median nerve N20 SSEP after 24 hours and an unreactive unprocessed EEG at 36 – 72 hours after ROSC
- Other clinical, laboratory and imaging indicators have insufficient evidence to support their use for prognostication where therapeutic hypothermia has been used.
References
- The 2010 ILCOR guidelines
- The Australian Resuscitation Council
- Emergency Medicine Australia, Vol 23, No 3, June 2011