ILCOR Guideline Changes 2010

OVERVIEW

ILCOR = International Liaison committee on Resuscitation = conglomerate of resuscitation councils worldwide

• AHA
• European Resuscitation Council
• Heart and Stroke Foundation of Canada
• Australia and New Zealand Committee on Resuscitation
• Resuscitation Councils of South Africa
• Inter American Heart Foundation
• Resuscitation Council of Asia (Japan, Korea, Singapore, Taiwan)

CHANGES IN 2010 GUIDELINES

Compressions Emphasis

• CAB rather than ABC
• minimise interruptions
• allow complete chest recoil
• at least 100/min rather than approximately 100/min
• compression depth: at least 5cm in adults and 4cm in infants
• no change in ratios: 30:2 adults and children (with children can go to 15:2)
• avoid excessive ventilation

Basic Life Support

• immediate recognition of unresponsiveness and activation of emergency response services
• initiation of CPR if unresponsive or not breathing normally
• look-listen-feel removed
• good quality CPR (push hard, push fast)

Advanced Life Support

• emphasis in minimizing duration of pre and post shock pauses
• CPR should not stop > 5 seconds
• early defibrillation (1 better than 3 stacked shocks) -> with immediate resumption of CPR is the important variable
• AED’s in hospitals and for children and infants now
• if initial shock unsuccessful -> give same or greater energy
• no CPR device has been shown to be superior to manual CPR
• precordial thump only for witnessed but should not delay defibrillation or CPR
• early intubation with minimal disruption to CPR (then continuous CPR with breaths 10/min)
• capnography recommended: ET tube placement, quality of CPR and detection of ROSC
• drugs:

-> atropine not recommended for PEA/asystole -> adrenaline 1mg Q 3 min -> amiodarone 300mg after 3rd shock -> don’t use ETT for drugs (IV or IO) -> adenosine used for diagnosis and treatment of unstable, undifferentiated, regular, monomorphic wide-complex tachycardia (don’t use in irregular wide-complex tachycardia)

• cardioversion:

-> AF: 120-200J (biphasic), 200J (monophasic) -> atrial flutter: 50-100J (bi or monophasic) -> stable VT: 100J (bi or monophasic)

Post Cardiac Arrest Care

• optimize cardiopulmonary function and perfusion
• transport to appropriate hospital (cath lab, neurological care, goal directed critical care, hypothermia)
• identify and treat precipitating causes
• avoid hyperoxia (SpO2 >94% but not 100%)
• primary PCI is appropriate in the comatosed with ROSC
• glucose < 10mmol/L
• therapeutic hypothermia
• traditional measures of prognosis @ 72 hrs are now not as predictive given benefits seen of therapeutic hypothermia.
• monitor for and treat seizures

Paediatric Life Support

• CAB (ERC still advocates 5 initial rescue breaths)
• good quality CPR
• removal of ‘look, listen, feel’
• de-emphasis on pulse check
• AED and defibrillation use encouraged (infants manual defibrillation)
• capnography recommended
• defibrillation: 2-4 J/kg
• avoid hyperoxia
• congenital heart disease: early use of ECMO advocated
• calcium use: only in hypocalcaemia, Ca2+ channel blocker OD, hypermagnasaemia, hyperkalaemia

Acute Coronary Syndromes

• out of hospital 12 lead ECG: reduce time to thrombolysis and PCI
• cardiac arrest and ACS if ischaemic in origin -> requires PCI (coma is not a contraindication)
• if saturations > 94% don’t require O2
• chest pain: use nitrates, use morphine cautiously (associated with increased mortality)

Stroke

• don’t manage BP pre-hospital
• improved outcomes with management in stroke unit
• rtPA within 3 hours of selected cases

Neonatal Resuscitation

• ABC resuscitation
• 3:1 compression to ventilation ratio (unless CVS in origin then 15:2)
• use of SpO2 on right wrist or palm (colour unreliable)
• start ventilation with air -> titrate O2 up (avoid hyperoxia)
• no need to suction vigorous babies (suction those with airway obstruction, obtunded or meconium)
• capnography encouraged
• therapeutic hypothermia (33.5-34.5 C)
• delayed cord clamping for 1 min beneficial in babies not requiring resuscitation

Ethical Issues

• cessation of care: — BLS (unwitnessed, no ROSC after 3 complete rounds (6min), no shocks indicated/delivered) — ALS (unwitnessed, no bystander CPR, no ROSC after complete ALS, no shocks delivered)
• prognostication difficult now as the work was done prior to therapeutic hypothermia

SUMMARY OF CHANGES

Compression’s emphasis

• CAB vs ABC
• early, high quality, uninterrupted
• atleast 100/min (rather than around)
• avoid excessive ventilation

Basic Life Support

• early call for EMS and starting of CPR (unresponsive and abnormal breathing)
• look-listen-feel removed
• ‘push hard, push fast’

Advanced Life Support

• minimise pauses in CPR
• early defibrillation (higher joules for cardioversion)
• capnography
• no atropine
• no ETT drugs (IV or IO)
• adenosine for unstable, undifferentiated, wide-complex tachycardia

Post cardiac Arrest Care

• transport to definitive and ICU care
• PCI in comatosed with ROSC
• therapeutic hypothermia
• avoid hyperglycaemia and hyperoxia
• ID and treat cause
• treat seizures

Other Issues

• paediatrics: AED use encouraged, congenital heart disease -> ECMO early
• neonates: ABC, 3:1, air -> titrate O2 up, don’t suction vigorous babies, therapeutic hypothermia, delayed cord clamping in those not compromised good
• ACS: field 12 lead ECG good, nitrates, caution with opioids
• stroke: tPA within 3 hours, don’t manage BP acutely, stoke units
• ethics: prognostication tools difficult to use know c/o therapeutic hypothermia, stopping advice