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

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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