2010年美国心脏病学会心肺复苏指南(英文版)

Cardiopulmonary Resuscitation and Emergency Cardiovascular Care John M. Field, Mary Fran Hazinski, Michael R. Sayre, Leon Chameides, Stephen M.Schexnayder, Robin Hemphill, Ricardo A. Samson, John Kattwinkel, Robert A. Berg, Farhan Bhanji, Diana M. Cave, Edward C. Jauch, Peter J. Kudenchuk, Robert W.Neumar, Mary Ann Peberdy, Jeffrey M. Perlman, Elizabeth Sinz, Andrew H. Travers, Marc D. Berg, John E. Billi, Brian Eigel, Robert W. Hickey, Monica E. Kleinman,Mark S. Link, Laurie J. Morrison, Robert E. O'Connor, Michael Shuster, Clifton W. Callaway, Brett Cucchiara, Jeffrey D. Ferguson, Thomas D. Rea and Terry L. Vanden

Hoek

Circulation 2010;122;S640-S656

DOI: 10.1161/CIRCULATIONAHA.110.970889

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Part1:ExecutiveSummary

2010AmericanHeartAssociationGuidelinesforCardiopulmonary

ResuscitationandEmergencyCardiovascularCare

JohnM.Field,Co-Chair*;MaryFranHazinski,Co-Chair*;MichaelR.Sayre;LeonChameides;StephenM.Schexnayder;RobinHemphill;RicardoA.Samson;JohnKattwinkel;RobertA.Berg;FarhanBhanji;DianaM.Cave;EdwardC.Jauch;PeterJ.Kudenchuk;RobertW.Neumar;MaryAnnPeberdy;JeffreyM.Perlman;ElizabethSinz;AndrewH.Travers;MarcD.Berg;

JohnE.Billi;BrianEigel;RobertW.Hickey;MonicaE.Kleinman;MarkS.Link;LaurieJ.Morrison;RobertE.O’Connor;MichaelShuster;CliftonW.Callaway;BrettCucchiara;JeffreyD.Ferguson;

ThomasD.Rea;TerryL.VandenHoek

hepublicationofthe2010AmericanHeartAssociationGuidelinesforCardiopulmonaryResuscitationandEmergencyCardiovascularCaremarksthe50thanniversaryofmodernCPR.In1960Kouwenhoven,Knickerbocker,andJudedocumented14patientswhosurvivedcardiacarrestwiththeapplicationofclosedchestcardiacmassage.1Thatsameyear,atthemeetingoftheMarylandMedicalSocietyinOceanCity,MD,thecombinationofchestcompressionsandrescuebreathingwasintroduced.2Twoyearslater,in1962,direct-current,monophasicwaveformdefibrillationwasde-scribed.3In1966theAmericanHeartAssociation(AHA)developedthefirstcardiopulmonaryresuscitation(CPR)guidelines,whichhavebeenfollowedbyperiodicupdates.4Duringthepast50yearsthefundamentalsofearlyrecogni-tionandactivation,earlyCPR,earlydefibrillation,andearlyaccesstoemergencymedicalcarehavesavedhundredsofthousandsoflivesaroundtheworld.Theselivesdemonstratetheimportanceofresuscitationresearchandclinicaltransla-tionandarecausetocelebratethis50thanniversaryofCPR.Challengesremainifwearetofulfillthepotentialofferedbythepioneerresuscitationscientists.Weknowthatthereisastrikingdisparityinsurvivaloutcomesfromcardiacarrestacrosssystemsofcare,withsomesystemsreporting5-foldhighersurvivalratesthanothers.5–9Althoughtechnology,suchasthatincorporatedinautomatedexternaldefibrillators(AEDs),hascontributedtoincreasedsurvivalfromcardiacarrest,noinitialinterventioncanbedeliveredtothevictimofcardiacarrestunlessbystandersareready,willing,andabletoact.Moreover,tobesuccessful,theactionsofbystandersandothercareprovidersmustoccurwithinasystemthatcoordi-natesandintegrateseachfacetofcareintoacomprehensivewhole,focusingonsurvivaltodischargefromthehospital.

T

Thisexecutivesummaryhighlightsthemajorchangesandmostprovocativerecommendationsinthe2010AHAGuide-linesforCPRandEmergencyCardiovascularCare(ECC).ThescientistsandhealthcareprovidersparticipatinginacomprehensiveevidenceevaluationprocessanalyzedthesequenceandprioritiesofthestepsofCPRinlightofcurrentscientificadvancestoidentifyfactorswiththegreatestpotentialimpactonsurvival.Onthebasisofthestrengthoftheavailableevidence,theydevelopedrecommendationstosupporttheinterventionsthatshowedthemostpromise.Therewasunanimoussupportforcontinuedemphasisonhigh-qualityCPR,withcompressionsofadequaterateanddepth,allowingcompletechestrecoil,minimizinginter-ruptionsinchestcompressionsandavoidingexcessiveventilation.High-qualityCPRisthecornerstoneofasystemofcarethatcanoptimizeoutcomesbeyondreturnofspontaneouscirculation(ROSC).Returntoapriorqualityoflifeandfunctionalstateofhealthistheultimategoalofaresuscitationsystemofcare.

The2010AHAGuidelinesforCPRandECCarebasedonthemostcurrentandcomprehensivereviewofresuscitationlitera-tureeverpublished,the2010ILCORInternationalConsensusonCPRandECCScienceWithTreatmentRecommendations.10The2010evidenceevaluationprocessincluded356resuscita-tionexpertsfrom29countrieswhoreviewed,analyzed,evalu-ated,debated,anddiscussedresearchandhypothesesthroughin-personmeetings,teleconferences,andonlinesessions(“web-inars”)duringthe36-monthperiodbeforethe2010ConsensusConference.Theexpertsproduced411scientificevidencere-viewson277topicsinresuscitationandemergencycardiovas-cularcare.Theprocessincludedstructuredevidenceevaluation,analysis,andcatalogingoftheliterature.Italsoincludedrigor-

TheAmericanHeartAssociationrequeststhatthisdocumentbecitedasfollows:FieldJM,HazinskiMF,SayreMR,ChameidesL,SchexnayderSM,HemphillR,SamsonRA,KattwinkelJ,BergRA,BhanjiF,CaveDM,JauchEC,KudenchukPJ,NeumarRW,PeberdyMA,PerlmanJM,SinzE,TraversAH,BergMD,BilliJE,EigelB,HickeyRW,KleinmanME,LinkMS,MorrisonLJ,O’ConnorRE,ShusterM,CallawayCW,CucchiaraB,FergusonJD,ReaTD,VandenHoekTL.Part1:executivesummary:2010AmericanHeartAssociationGuidelinesforCardiopulmonaryResuscitationandEmergencyCardiovascularCare.Circulation.2010;122(suppl3):S640–S656.*Co-chairsandequalfirstco-authors.

(Circulation.2010;122[suppl3]:S640–S656.)©2010AmericanHeartAssociation,Inc.Circulationisavailableathttp://circ.ahajournals.org

DOI:10.1161/CIRCULATIONAHA.110.970889

S640Downloaded from circ.ahajournals.org by on October 21, 2010

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ousdisclosureandmanagementofpotentialconflictsofinterest,whicharedetailedinPart2:“EvidenceEvaluationandMan-agementofPotentialandPerceivedConflictsofInterest.”

Therecommendationsinthe2010Guidelinesconfirmthesafetyandeffectivenessofmanyapproaches,acknowledgeineffectivenessofothers,andintroducenewtreatmentsbasedonintensiveevidenceevaluationandconsensusofexperts.Thesenewrecommendationsdonotimplythatcareusingpastguidelinesiseitherunsafeorineffective.Inaddition,itisimportanttonotethattheywillnotapplytoallrescuersandallvictimsinallsituations.Theleaderofaresuscitationattemptmayneedtoadaptapplicationoftheserecommenda-tionstouniquecircumstances.

Part1:ExecutiveSummaryS641

andgovernmentregulators,medicaldirection,andparticipa-tioninresearch).

DocumentingtheEffectsofCPRPerformancebyLayRescuers

Duringthepast5yearstherehasbeenanefforttosimplifyCPRrecommendationsandemphasizethefundamentalimportanceofhigh-qualityCPR.Largeobservationalstudiesfrominvestiga-torsinmembercountriesoftheResuscitationCouncilofAsia(thenewestmemberofILCOR)27,28–30andotherstudies31,32haveprovidedimportantinformationaboutthepositiveimpactofbystanderCPRonsurvivalafterout-of-hospitalcardiacarrest.Formostadultswithout-of-hospitalcardiacarrest,bystanderCPRwithchestcompressiononly(Hands-OnlyCPR)appearstoachieveoutcomessimilartothoseofconventionalCPR(com-pressionswithrescuebreathing).28–32However,forchildren,conventionalCPRissuperior.27NewDevelopmentsinResuscitationScience

Since2005

Auniversalcompression-ventilationratioof30:2performedbylonerescuersforvictimsofallageswasoneofthemostcontroversialtopicsdiscussedduringthe2005InternationalConsensusConference,anditwasamajorchangeinthe2005AHAGuidelinesforCPRandECC.11In2005ratesofsurvivaltohospitaldischargefromwitnessedout-of-hospitalsuddencardiacarrestduetoventricularfibrillation(VF)werelow,averagingՅ6%worldwidewithlittleimprovementintheyearsimmediatelyprecedingthe2005conference.5Twostudiespublishedjustbeforethe2005InternationalConsen-susConferencedocumentedpoorqualityofCPRperformedinbothout-of-hospitalandin-hospitalresuscitations.12,13Thechangesinthecompression-ventilationratioandinthedefibrillationsequence(from3stackedshocksto1shockfollowedbyimmediateCPR)wererecommendedtomini-mizeinterruptionsinchestcompressions.11–13Therehavebeenmanydevelopmentsinresuscitationsciencesince2005,andthesearehighlightedbelow.

CPRQuality

Minimizingtheintervalbetweenstoppingchestcompressionsanddeliveringashock(ie,minimizingthepreshockpause)improvesthechancesofshocksuccess33,34andpatientsur-vival.33–35DatadownloadedfromCPR-sensingandfeedback-enableddefibrillatorsprovidevaluableinformationtoresus-citationteams,whichcanimproveCPRquality.36Thesedataaredrivingmajorchangesinthetrainingofin-hospitalresuscitationteamsandout-of-hospitalhealthcareproviders.

In-HospitalCPRRegistries

TheNationalRegistryofCardioPulmonaryResuscitation(NRCPR)37andotherlargedatabasesareprovidingnewinfor-mationabouttheepidemiologyandoutcomesofin-hospitalresuscitationinadultsandchildren.8,38–44Althoughobserva-tionalinnature,registriesprovidevaluabledescriptiveinforma-tiontobettercharacterizecardiacarrestandresuscitationout-comesaswellasidentifyareasforfurtherresearch.

EmergencyMedicalServicesSystemsandCPRQuality

Emergencymedicalservices(EMS)systemsandhealthcareprovidersshouldidentifyandstrengthen“weaklinks”intheChainofSurvival.ThereisevidenceofconsiderableregionalvariationinthereportedincidenceandoutcomefromcardiacarrestwithintheUnitedStates.5,14Thisevidencesupportstheimportanceofaccuratelyidentifyingeachinstanceoftreatedcardiacarrestandmeasuringoutcomesandsuggestsadditionalopportunitiesforimprovingsurvivalratesinmanycommunities.Recentstudieshavedemonstratedimprovedoutcomefromout-of-hospitalcardiacarrest,particularlyfromshockablerhythms,andhavereaffirmedtheimportanceofastrongeremphasisoncompressionsofadequaterateanddepth,allowingcompletechestrecoilaftereachcompression,minimizinginterrup-tionsincompressionsandavoidingexcessiveventilation.15–22Implementationofnewresuscitationguidelineshasbeenshowntoimproveoutcomes.18,20–22Ameansofexpeditingguidelinesimplementation(aprocessthatmaytakefrom18monthsto4years23–26)isneeded.Impedimentstoimplemen-tationincludedelaysininstruction(eg,timeneededtoproducenewtrainingmaterialsandupdateinstructorsandproviders),technologyupgrades(eg,reprogrammingAEDs),anddecisionmaking(eg,coordinationwithalliedagencies

DeemphasisonDevicesandAdvanced

CardiovascularLifeSupportDrugsDuringCardiacArrest

Atthetimeofthe2010InternationalConsensusConferencetherewerestillinsufficientdatatodemonstratethatanydrugsormechanicalCPRdevicesimprovelong-termoutcomeaftercardiacarrest.45Clearlyfurtherstudies,adequatelypoweredtodetectclinicallyimportantoutcomedifferenceswiththeseinterventions,areneeded.

ImportanceofPost–CardiacArrestCare

Organizedpost–cardiacarrestcarewithanemphasisonmultidisciplinaryprogramsthatfocusonoptimizinghemo-dynamic,neurologic,andmetabolicfunction(includingther-apeutichypothermia)mayimprovesurvivaltohospitaldis-chargeamongvictimswhoachieveROSCfollowingcardiacarresteitherin-orout-of-hospital.46–48Althoughitisnotyetpossibletodeterminetheindividualeffectofmanyofthesetherapies,whenbundledasanintegratedsystemofcare,theirdeploymentmaywellimproveoutcomes.

Therapeutichypothermiaisoneinterventionthathasbeenshowntoimproveoutcomeforcomatoseadultvictimsof

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witnessedout-of-hospitalcardiacarrestwhenthepresentingrhythmwasVF.49,50Since2005,twononrandomizedstudieswithconcurrentcontrolsaswellasotherstudiesusinghistoriccontrolshaveindicatedthepossiblebenefitofhypo-thermiafollowingin-andout-of-hospitalcardiacarrestfromallotherinitialrhythmsinadults.46,51–56Hypothermiahasalsobeenshowntobeeffectiveinimprovingintactneurologicsurvivalinneonateswithhypoxic-ischemicencephalopa-thy,57–61andtheresultsofaprospectivemulticenterpediatricstudyoftherapeutichypothermiaaftercardiacarrestareeagerlyawaited.

Manystudieshaveattemptedtoidentifycomatosepost–cardiacarrestpatientswhohavenoprospectformeaningfulneurologicrecovery,anddecisionrulesforprognosticationofpooroutcomehavebeenproposed.62Therapeutichypother-miachangesthespecificityofprognosticationdecisionrulesthatwerepreviouslyestablishedfromstudiesofpost–cardiacarrestpatientsnottreatedwithhypothermia.Recentreportshavedocumentedoccasionalgoodoutcomesinpost–cardiacarrestpatientswhoweretreatedwiththerapeutichypother-mia,despiteneurologicexamorneuroelectrophysiologicstudiesthatpredictedpooroutcome.63,64●

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EducationandImplementation

Thequalityofrescuereducationandfrequencyofretrainingarecriticalfactorsinimprovingtheeffectivenessofresusci-tation.65–83Ideallyretrainingshouldnotbelimitedto2-yearintervals.Morefrequentrenewalofskillsisneeded,withacommitmenttomaintenanceofcertificationsimilartothatembracedbymanyhealthcare-credentialingorganizations.Resuscitationinterventionsareoftenperformedsimulta-neously,andrescuersmustbeabletoworkcollaborativelytominimizeinterruptionsinchestcompressions.Teamworkandleadershipskillscontinuetobeimportant,particularlyforadvancedcardiovascularlifesupport(ACLS)andpediatricadvancedlifesupport(PALS)providers.36,84–89Communityandhospital-basedresuscitationprogramsshouldsystematicallymonitorcardiacarrests,thelevelofresuscitationcareprovided,andoutcome.Thecycleofmeasurement,interpretation,feedback,andcontinuousqual-ityimprovementprovidesfundamentalinformationnecessarytooptimizeresuscitationcareandshouldhelptonarrowtheknowledgeandclinicalgapsbetweenidealandactualresus-citationperformance.

Thevastmajorityofcardiacarrestsoccurinadults,andthehighestsurvivalratesfromcardiacarrestarereportedamongpatientsofallageswithwitnessedarrestandarhythmofVForpulselessventriculartachycardia(VT).InthesepatientsthecriticalinitialelementsofCPRarechestcompressionsandearlydefibrillation.90IntheA-B-Csequencechestcompressionsareoftendelayedwhiletheresponderopenstheairwaytogivemouth-to-mouthbreathsorretrievesabarrierdeviceorotherventilationequipment.BychangingthesequencetoC-A-B,chestcompressionswillbeinitiatedsoonerandventilationonlyminimallydelayeduntilcompletionofthefirstcycleofchestcompressions(30compressionsshouldbeaccomplishedinapproximately18seconds).

Fewerthan50%ofpersonsincardiacarrestreceivebystanderCPR.Thereareprobablymanyreasonsforthis,butoneimpedimentmaybetheA-B-Csequence,whichstartswiththeproceduresthatrescuersfindmostdifficult:openingtheairwayanddeliveringrescuebreaths.StartingwithchestcompressionsmightensurethatmorevictimsreceiveCPRandthatrescuerswhoareunableorunwillingtoprovideventilationswillatleastperformchestcompressions.Itisreasonableforhealthcareproviderstotailorthesequenceofrescueactionstothemostlikelycauseofarrest.Forexample,ifalonehealthcareproviderseesavictimsuddenlycollapse,theprovidermayassumethatthevictimhassufferedasuddenVFcardiacarrest;oncetheproviderhasverifiedthatthevictimisunresponsiveandnotbreathingorisonlygasping,theprovidershouldimmediatelyactivatetheemergencyresponsesystem,getanduseanAED,andgiveCPR.Butforapresumedvictimofdrowningorotherlikelyasphyxialarresttheprioritywouldbetoprovideabout5cycles(about2minutes)ofconventionalCPR(includingrescuebreathing)beforeac-tivatingtheemergencyresponsesystem.Also,innewlyborninfants,arrestismorelikelytobeofarespiratoryetiology,andresuscitationshouldbeattemptedwiththeA-B-Csequenceunlessthereisaknowncardiacetiology.

EthicalIssues

Theethicalissuessurroundingresuscitationarecomplexandvaryacrosssettings(in-orout-of-hospital),providers(basicoradvanced),andwhethertostartorhowtoterminateCPR.Recentworksuggeststhatacknowledgmentofaverbaldo-not-attempt-resuscitationorder(DNAR)inadditiontothecurrentstan-dard—awritten,signed,anddatedDNARdocument—maydecreasethenumberoffutileresuscitationattempts.91,92Thisisanimportantfirststepinexpandingtheclinicaldecisionrulepertainingtowhentostartresuscitationinout-of-hospitalcar-diacarrest.However,thereisinsufficientevidencetosupportthisapproachwithoutfurthervalidation.

WhenonlyBLS-trainedEMSpersonnelareavailable,terminationofresuscitativeeffortsshouldbeguidedbyavalidatedterminationofresuscitationrulethatreducesthetransportrateofattemptedresuscitationswithoutcompro-misingthecareofpotentiallyviablepatients.93Advancedlifesupport(ALS)EMSprovidersmayusethesameterminationofresuscitationrule94–99oraderivednonvali-datedrulespecifictoALSprovidersthatwhenappliedwill

Highlightsofthe2010Guidelines

TheChangeFrom“A-B-C”to“C-A-B”

Thenewestdevelopmentinthe2010AHAGuidelinesforCPRandECCisachangeinthebasiclifesupport(BLS)sequenceofstepsfrom“A-B-C”(Airway,Breathing,Chestcompressions)to“C-A-B”(Chestcompressions,Airway,Breathing)foradultsandpediatricpatients(childrenandinfants,excludingnewlyborns).Althoughtheexpertsagreedthatitisimportanttoreducetimetofirstchestcompressions,theywereawarethatachangeinsomethingasestablishedastheA-B-Csequencewouldrequirere-educationofeveryonewhohaseverlearnedCPR.The2010AHAGuidelinesforCPRandECCrecommendthischangeforthefollowingreasons:

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decreasethenumberoffutiletransportstotheemergencydepartment(ED).95,97–100Certaincharacteristicsofaneonatalin-hospitalcardiacarrestareassociatedwithdeath,andthesemaybehelpfulinguidingphysiciansinthedecisiontostartandstopaneonatalresuscitationattempt.101–104Thereismorevariabilityinter-minatingresuscitationratesacrosssystemsandphysicianswhenclinicaldecisionrulesarenotfollowed,suggestingthatthesevalidatedandgeneralizedrulesmaypromoteuniformityinaccesstoresuscitationattemptsandfullprotocolcare.105Offeringselectfamilymemberstheopportunitytobepresentduringtheresuscitationanddesignatingstaffwithintheteamtorespondtotheirquestionsandoffercomfortmayenhancetheemotionalsupportprovidedtothefamilyduringcardiacarrestandafterterminationofaresuscitationattempt.Identifyingpatientsduringthepost–cardiacarrestperiodwhodonothavethepotentialformeaningfulneurologicrecoveryisamajorclinicalchallengethatrequiresfurtherresearch.Cautionisadvisedwhenconsideringlimitingcareorwithdrawinglife-sustainingtherapy.Characteristicsortestresultsthatarepredictiveofpooroutcomeinpost–cardiacarrestpatientsnottreatedwiththerapeutichypothermiamaynotbeaspredictiveofpooroutcomeafteradministrationoftherapeutichypothermia.Becauseofthegrowingneedfortransplanttissueandorgans,allproviderteamswhotreatpostarrestpatientsshouldalsoplanandimplementasystemoftissueandorgandonationthatistimely,effective,andsupportiveoffamilymembersforthesubsetofpatientsinwhombraindeathisconfirmedorfororgandonationaftercardiacarrest.

Resuscitationresearchischallenging.Itmustbescientificallyrigorouswhileconfrontingethical,regulatory,andpublicrela-tionsconcernsthatarisefromtheneedtoconductsuchresearchwithexceptiontoinformedconsent.Regulatoryrequirements,communitynotification,andconsultationrequirementsoftenimposeexpensiveandtime-consumingdemandsthatmaynotonlydelayimportantresearchbutalsorenderitcost-prohibitive,withlittlesignificantevidencethatthesemeasureseffectivelyaddresstheconcernsaboutresearch.106–109●

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EncourageHands-Only(compressiononly)CPRfortheuntrainedlayrescuer.Hands-OnlyCPRiseasiertoperformbythosewithnotrainingandcanbemorereadilyguidedbydispatchersoverthetelephone.

Initiatechestcompressionsbeforegivingrescuebreaths(C-A-BratherthanA-B-C).Chestcompressionscanbestartedimmediately,whereaspositioningthehead,attainingasealformouth-to-mouthrescuebreathing,orobtainingorassemblingabag-maskdeviceforrescuebreathingalltaketime.Begin-ningCPRwith30compressionsratherthan2ventilationsleadstoashorterdelaytofirstcompression.

Thereisanincreasedfocusonmethodstoensurethathigh-qualityCPRisperformed.Adequatechestcompres-sionsrequirethatcompressionsbeprovidedattheappro-priatedepthandrate,allowingcompleterecoilofthechestaftereachcompressionandanemphasisonminimizinganypausesincompressionsandavoidingexcessiveventilation.Trainingshouldfocusonensuringthatchestcompressionsareperformedcorrectly.Therecommendeddepthofcom-pressionforadultvictimshasincreasedfromadepthof11⁄2to2inchestoadepthofatleast2inches.

Manytasksperformedbyhealthcareprovidersduringresus-citationattempts,suchaschestcompressions,airwayman-agement,rescuebreathing,rhythmdetection,shockdelivery,anddrugadministration(ifappropriate),canbeperformedconcurrentlybyanintegratedteamofhighlytrainedrescuersinappropriatesettings.Someresuscitationsstartwithalonerescuerwhocallsforhelp,resultinginthearrivalofadditionalteammembers.Healthcareprovidertrainingshouldfocusonbuildingtheteamaseachmemberarrivesorquicklydelegat-ingrolesifmultiplerescuersarepresent.Asadditionalpersonnelarrive,responsibilitiesfortasksthatwouldordi-narilybeperformedsequentiallybyfewerrescuersmaynowbedelegatedtoateamofproviderswhoshouldperformthemsimultaneously.

KeyPointsofContinuedEmphasisforthe2010AHAGuidelinesforCPRandECC

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BasicLifeSupport

BLSisthefoundationforsavinglivesfollowingcardiacarrest.FundamentalaspectsofadultBLSincludeimmediaterecognitionofsuddencardiacarrestandactivationoftheemergencyresponsesystem,earlyperformanceofhigh-qualityCPR,andrapiddefibrillationwhenappropriate.The2010AHAGuidelinesforCPRandECCcontainseveralimportantchangesbutalsohaveareasofcontinuedemphasisbasedonevidencepresentedinprioryears.

KeyChangesinthe2010AHAGuidelinesforCPRandECC

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TheBLSalgorithmhasbeensimplified,and“Look,ListenandFeel”hasbeenremovedfromthealgorithm.Performanceofthesestepsisinconsistentandtimeconsuming.Forthisreasonthe2010AHAGuidelinesforCPRandECCstressimmediateactivationoftheemergencyresponsesystemandstartingchestcompressionsforanyunresponsiveadultvictimwithnobreathingornonormalbreathing(ie,onlygasps).

Earlyrecognitionofsuddencardiacarrestinadultsisbasedonassessingresponsivenessandtheabsenceofnormalbreathing.Victimsofcardiacarrestmayinitiallyhavegaspingrespirationsorevenappeartobehavingaseizure.Theseatypicalpresentationsmayconfusearescuer,caus-ingadelayincallingforhelporbeginningCPR.Trainingshouldfocusonalertingpotentialrescuerstotheunusualpresentationsofsuddencardiacarrest.

MinimizeinterruptionsineffectivechestcompressionsuntilROSCorterminationofresuscitativeefforts.Anyunnecessaryinterruptionsinchestcompressions(includinglongerthannecessarypausesforrescuebreathing)de-creasesCPReffectiveness.

Minimizetheimportanceofpulsechecksbyhealthcareproviders.Detectionofapulsecanbedifficult,andevenhighlytrainedhealthcareprovidersoftenincorrectlyassessthepresenceorabsenceofapulsewhenbloodpressureisabnormallyloworabsent.Healthcareprovidersshouldtakenomorethan10secondstodetermineifapulseispresent.Chestcompressionsdeliveredtopatientssubsequentlyfoundnottobeincardiacarrestrarelyleadtosignificant

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presentCPRshouldbeperformedwhileadefibrillatorisbeingobtainedandreadiedforuse.

The1-shockprotocolforVFhasnotbeenchanged.EvidencehasaccumulatedthatevenshortinterruptionsinCPRareharmful.Thus,rescuersshouldminimizetheintervalbetweenstoppingcompressionsanddeliveringshocksandshouldresumeCPRimmediatelyaftershockdelivery.

Overthelastdecadebiphasicwaveformshavebeenshowntobemoreeffectivethanmonophasicwaveformsincardio-versionanddefibrillation.127–135However,therearenoclin-icaldatacomparingonespecificbiphasicwaveformwithanother.Whetherescalatingorfixedsubsequentdosesofenergyaresuperiorhasnotbeentestedwithdifferentwave-forms.However,ifhigherenergylevelsareavailableinthedeviceathand,theymaybeconsideredifinitialshocksareunsuccessfulinterminatingthearrhythmia.

Inthelast5to10yearsanumberofrandomizedtrialshavecomparedbiphasicwithmonophasiccardioversioninatrialfibrillation.Theefficacyofshockenergiesforcardioversionofatrialfibrillationiswaveform-specificandcanvaryfrom120to200Jdependingonthedefibrillatormanufacturer.Thus,therecommendedinitialbiphasicenergydoseforcardioversionofatrialfibrillationis120to200Jusingthemanufacturer’srecommendedsetting.136–140Iftheinitialshockfails,providersshouldincreasethedoseinastepwisefashion.Cardiover-sionofadultatrialflutterandothersupraventriculartachycardiasgenerallyrequireslessenergy;aninitialenergyof50Jto100Jisoftensufficient.140Iftheinitialshockfails,providersshouldincreasethedoseinastepwisefashion.141Adultcardioversionofatrialfibrilla-tionwithmonophasicwaveformsshouldbeginat200Jandincreaseinastepwisefashionifnotsuccessful.

Transcutaneouspacinghasalsobeenthefocusofseveralrecenttrials.Pacingisnotgenerallyrecommendedforpa-tientsinasystoliccardiacarrest.Threerandomizedcontrolledtrials142–144indicatenoimprovementinrateofadmissiontohospitalorsurvivaltohospitaldischargewhenparamedicsorphysiciansattemptedpacinginpatientswithcardiacarrestduetoasystoleintheprehospitalorhospital(ED)setting.However,itisreasonableforhealthcareproviderstobepreparedtoinitiatepacinginpatientswithbradyarrhythmiasintheeventtheheartratedoesnotrespondtoatropineorotherchronotropic(rate-accelerating)drugs.145,146injury.110Thelayrescuershouldactivatetheemergencyresponsesystemifheorshefindsanunresponsiveadult.Thelayrescuershouldnotattempttocheckforapulseandshouldassumethatcardiacarrestispresentifanadultsuddenlycollapses,isunresponsive,andisnotbreathingornotbreathingnormally(ie,onlygasping).

CPRTechniquesandDevices

AlternativestoconventionalmanualCPRhavebeendevel-opedinanefforttoenhanceperfusionduringresuscitationfromcardiacarrestandtoimprovesurvival.ComparedwithconventionalCPR,thesetechniquesanddevicestypicallyrequiremorepersonnel,training,andequipment,orapplytoaspecificsetting.SomealternativeCPRtechniquesanddevicesmayimprovehemodynamicsorshort-termsurvivalwhenusedbywell-trainedprovidersinselectedpatients.Severaldeviceshavebeenthefocusofrecentclinicaltrials.Useoftheimpedancethresholddevice(ITD)improvedROSCandshort-termsurvivalwhenusedinadultswithout-of-hospitalcardiacarrest,buttherewasnosignificantimprovementineithersurvivaltohospitaldischargeorneurologically-intactsurvivaltodischarge.111Onemulticenter,prospective,randomizedcon-trolledtrial112,112acomparingload-distributingbandCPR(Auto-pulse)withmanualCPRforout-of-hospitalcardiacarrestdemonstratednoimprovementin4-hoursurvivalandworseneurologicoutcomewhenthedevicewasused.Moreresearchisneededtodetermineifsite-specificfactors113orexperiencewithdeploymentofthedevice114influenceeffectivenessoftheload-distributingbandCPRdevice.Caseseriesemployingme-chanicalpistondeviceshavereportedvariabledegreesofsuccess.115–119Topreventdelaysandmaximizeefficiency,initialtraining,ongoingmonitoring,andretrainingprogramsshouldbeofferedonafrequentbasistoprovidersusingCPRdevices.Todate,noadjuncthasconsistentlybeenshowntobesuperiortostandardconventional(manual)CPRforout-of-hospitalBLS,andnodeviceotherthanadefibrillatorhasconsistentlyimprovedlong-termsurvivalfromout-of-hospitalcardiacarrest.

ElectricalTherapies

The2010AHAGuidelinesforCPRandECChavebeenupdatedtoreflectnewdataontheuseofpacinginbradycar-dia,andoncardioversionanddefibrillationfortachycardicrhythmdisturbances.IntegrationofAEDsintoasystemofcareiscriticalintheChainofSurvivalinpublicplacesoutsideofhospitals.Togivethevictimthebestchanceofsurvival,3actionsmustoccurwithinthefirstmomentsofacardiacarrest120:activationoftheEMSsystem,121provisionofCPR,andoperationofadefibrillator.122OneareaofcontinuedinterestiswhetherdeliveringalongerperiodofCPRbeforedefibrillationimprovesout-comesincardiacarrest.Inearlystudies,survivalwasim-provedwhen1.5to3minutesofCPRprecededdefibrillationforpatientswithcardiacarrestofϾ4to5minutesdurationpriortoEMSarrival.123,124However,in2morerecentrandomizedcontrolledtrials,CPRperformedbeforedefibril-lationdidnotimproveoutcome.125,126IfՆ2rescuersare

AdvancedCardiovascularLifeSupport

ACLSaffectsmultiplelinksintheChainofSurvival,includinginterventionstopreventcardiacarrest,treatcardiacarrest,andimproveoutcomesofpatientswhoachieveROSCaftercardiacarrest.The2010AHAGuidelinesforCPRandECCcontinuetoemphasizethatthefoundationofsuccessfulACLSisgoodBLS,beginningwithprompthigh-qualityCPRwithminimalinterrup-tions,andforVF/pulselessVT,attempteddefibrillationwithinminutesofcollapse.ThenewfifthlinkintheChainofSurvivalandPart9:“Post–CardiacArrestCare”(expandedfromasubsectionoftheACLSpartofthe2005AHAGuidelinesforCPRandECC)emphasizetheimportanceofcomprehensivemultidisciplinarycarethatbeginswithrecognitionofcardiacarrestandcontinuesafterROSCthroughhospitaldischargeandbeyond.KeyACLSassessmentsandinterventionsprovidean

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essentialbridgebetweenBLSandlong-termsurvivalwithgoodneurologicfunction.

Intermsofairwaymanagementthe2010AHAGuidelinesforCPRandECChaveamajornewClassIrecommendationforadults:useofquantitativewaveformcapnographyforconfirmationandmonitoringofendotrachealtubeplacement.Inaddition,theuseofsupraglotticadvancedairwayscontin-uestobesupportedasanalternativetoendotrachealintuba-tionforairwaymanagementduringCPR.Finally,theroutineuseofcricoidpressureduringairwaymanagementofpatientsincardiacarrestisnolongerrecommended.

Thereareseveralimportantchangesinthe2010AHAGuidelinesforCPRandECCregardingmanagementofsymptomaticarrhythmias.Onthebasisofnewevidenceofsafetyandpotentialefficacy,adenosinecannowbeconsid-eredforthediagnosisandtreatmentofstableundifferentiatedwide-complextachycardiawhentherhythmisregularandtheQRSwaveformismonomorphic.Forsymptomaticorunsta-blebradycardia,intravenous(IV)infusionofchronotropicagentsisnowrecommendedasanequallyeffectivealterna-tivetoexternalpacingwhenatropineisineffective.

For2010anewcircularAHAACLSCardiacArrestAlgo-rithmhasbeenintroducedasanalternativetothetraditionalbox-and-lineformat.Bothalgorithmsrepresentrestructuredandsimplifiedformatsthatfocusoninterventionsthathavethegreatestimpactonoutcome.Tothatend,emphasishasbeenplacedondeliveryofhigh-qualityCPRwithminimalinterrup-tionsanddefibrillationofVF/pulselessVT.Vascularaccess,drugdelivery,andadvancedairwayplacement,whilestillrecommended,shouldnotcausesignificantinterruptionsinchestcompressionordelayshocks.Inaddition,atropineisnolongerrecommendedforroutineuseinthemanagementofpulselesselectricalactivity(PEA)/asystole.

Real-timemonitoringandoptimizationofCPRqualityusingeithermechanicalparameters(eg,monitoringofchestcompressionrateanddepth,adequacyofchestwallrelax-ation,lengthanddurationofpausesincompressionandnumberanddepthofventilationsdelivered)or,whenfeasi-ble,physiologicparameters(partialpressureofend-tidalCO2[PETCO2],arterialpressureduringtherelaxationphaseofchestcompressions,orcentralvenousoxygensaturation[ScvO2])areencouraged.Whenquantitativewaveformcap-nographyisusedforadults,guidelinesnowincluderecom-mendationsformonitoringCPRqualityanddetectingROSCbasedonPETCO2values.

Finallythe2010AHAGuidelinesforCPRandECCcontinuetorecognizethatACLSdoesnotendwhenapatientachievesROSC.Guidelinesforpost–cardiacarrestman-agementhavebeensignificantlyexpanded(seePart9)andnowincludeanewEarlyPost–CardiacArrestTreatmentAlgorithm.

Part1:ExecutiveSummaryS645

interventionstoachieveoptimaloutcomeinvictimsofcardiacarrestwhoareadmittedtoahospitalfollowingROSC.Werecommendthatacomprehensive,structured,integrated,multidisciplinarysystemofcareshouldbeimple-mentedinaconsistentmannerforthetreatmentofpost–cardiacarrestpatients.

Initialandlaterkeyobjectivesofpost–cardiacarrestcareinclude

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Optimizingcardiopulmonaryfunctionandvitalorganper-fusionafterROSC

Transportationtoanappropriatehospitalorcritical-careunitwithacomprehensivepost–cardiacarresttreatmentsystemofcare

Identificationandinterventionforacutecoronarysyn-dromes(ACS)

Temperaturecontroltooptimizeneurologicrecovery

Anticipation,treatment,andpreventionofmultipleorgandysfunction

Theprimarygoalofabundledtreatmentstrategyforthepatientaftercardiacarrestincludesaconsistentlyappliedcomprehensivetherapeuticplandeliveredinamultidisci-plinaryenvironmentleadingtothereturnofnormalornear-normalfunctionalstatus.PatientswithsuspectedACSshouldbetriagedtoafacilitywithreperfusioncapabilitiesandamultidisciplinaryteampreparedtomonitorpatientsformulti-organdysfunctionandinitiateappropriatepost–cardiacarresttherapy,includinghypothermia.Prognosticassessmentinthesettingofhypothermiaischanging,andexpertsqualifiedinneurologicassessmentinthispatientpopulationandintegrationofprognostictoolsareessentialforpatients,caregivers,andfamiliesandarereviewedindetailinPart9.Asaguidetotherapy,anewalgorithmandatableofintegratedgoaltherapycareweredeveloped.

StabilizationofthePatientWithACS

The2010AHAGuidelinesforCPRandECCrecommenda-tionsfortheevaluationandmanagementofACShavebeenupdatedtodefinethescopeoftrainingforhealthcareprovid-erswhotreatpatientswithsuspectedordefiniteACSwithinthefirsthoursafteronsetofsymptoms.WithinthiscontextseveralimportantstrategiesandcomponentsofcarearedefinedandemphasizedbytheseguidelinesandincludesystemsofcareforpatientswithST-elevationmyocardialinfarction(STEMI),prehospital12-leadelectrocardiograms(ECGs),triagetohospitalscapableofperformingpercutane-ouscoronaryintervention(PCI),andcomprehensivecareforpatientsfollowingcardiacarrestwithconfirmedSTEMIorsuspectedACS.

Awell-organizedapproachtoSTEMIcarerequiresinte-grationofcommunity,EMS,physician,andhospitalre-sourcesinabundledSTEMIsystemofcare.AnimportantandkeycomponentofSTEMIsystemsofcareistheperformanceofprehospital12-leadECGswithtransmissionorinterpretationbyEMSprovidersandadvancenotificationofthereceivingfacility.Useofprehospital12-leadECGshasbeenrecommendedbytheAHAGuidelinesforCPRandECCsince2000andhasbeendocumentedtoreducetimeto

Post–CardiacArrestCare

The2010AHAGuidelinesforCPRandECCrecognizetheincreasedimportanceofsystematiccareandadvancementsinthemultispecialtymanagementofpatientsfollowingROSCandadmissiontothehospitalthatcanaffectneurologicallyintactsurvival.Part9:“Post–CardiacArrestCare”recognizestheimportanceofbundledgoal-orientedmanagementand

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teamandinstitutionalcommitment.However,itisimportanttoemphasizethecontinuedtime-dependentreperfusionwin-dowandthatearliertreatmentisbetterandisassociatedwithimprovedoutcome.PatientsineligibleforstandardIVfi-brinolytictherapymaybeconsideredforintra-arterialfi-brinolytictherapyormechanicalrevascularizationatselectedcenterswithspecializedcapabilities.

Finallytheseguidelinesrecommendadmissiontoastrokeunitwithin3hoursofpresentationtotheED.Recentstudiesestablishthatstrokeunitcareissuperiortocareingeneralmedicalwards,andpositiveeffectsofstrokeunitcarecanpersistforyears.ThebenefitsfromtreatmentinastrokeunitarecomparabletothebeneficialeffectsachievedwithIVrtPA.

OverallstrokecarehasprogresseddramaticallysinceitwasfirstincorporatedintotheECCmission.Improvementsineducation,prehospitalmanagement,hospitalsystemdevelop-ment,andacutetreatmentshaveleadtosignificantimprove-mentsinpatientoutcomes.

reperfusionwithfibrinolytictherapy.147–153Morerecently,prehospital12-leadECGshavealsobeenshowntoreducethetimetoprimarypercutaneouscoronaryintervention(PCI)andcanfacilitatetriagetospecifichospitalswhenPCIisthechosenstrategy.154–161WhenEMSorEDphysiciansactivatethecardiaccareteam,includingthecardiaccatheterizationlaboratory,significantreductionsinreperfusiontimesareobserved.

TheACSguidelinesalsomakenewrecommendationsfortriageofpatientstoPCIcentersaftercardiacarrest.TheperformanceofPCIhasbeenassociatedwithfavorableoutcomesinadultpatientsresuscitatedfromcardiacarrest,anditisreasonabletoincludecardiaccatheterizationinstandardizedpost–cardiacarrestprotocolsaspartofanoverallstrategytoimproveneurologicallyintactsurvivalinthispatientgroup.Inpatientswithout-of-hospitalcardiacarrestduetoVF,emergentangiographywithpromptrevascularizationoftheinfarct-relatedarteryisrecommended.TheECGmaybeinsensitiveormisleadingfollowingcardiacarrest,andcoronaryangiographyafterROSCinsubjectswitharrestofpresumedischemiccardiacetiologymaybereasonable,evenintheabsenceofaclearlydefinedSTEMI.ClinicalfindingsofcomainpatientsbeforePCIarecommonfollowingout-of-hospitalcardiacarrestandshouldnotbeacontraindicationtoconsider-ationofimmediateangiographyandPCI.

SpecialSituations

Cardiacarrestinspecialsituationsmayrequirespecialtreatmentsorproceduresbeyondthoseprovidedduringstan-dardBLSorACLS.Becauseofdifficultyinconductingrandomizedclinicaltrialsintheseareasortheirinfrequentoccurrence,theseuniquesituationscallforanexperiencedprovidertogo“beyondbasics,”usingclinicalconsensusandextrapolationfromtypicalcircumstances.Thetopicscoveredinthe2005AHAGuidelinesforCPRandECChavebeenreviewed,updated,andexpandedto15specificcardiacarrestsituations.Theseguidelinesemphasizethe“aboveandbe-yond”knowledgerequiredaswellastheanticipatoryclinicalacumentoprovidetimelycareanduniqueinterventions.Topicsincludesignificantperiarrestfeaturesthatmaybeimportanttopreventcardiacarrestorthatrequirespecialpost–cardiacarrestcareandinterventionbeyondtheusualcaredefinedintheseguidelines.Topicswiththesepotentiallyuniquefeaturesincludeasthma,anaphylaxis,pregnancy,morbidobesity,pulmonaryembolism,electrolyteimbalance,ingestionoftoxicsubstances,trauma,accidentalhypother-mia,avalanche,drowning,electricshock/lightningstrikes,andspecialproceduralsituationsaffectingtheheart,includ-ingPCI,cardiactamponade,andcardiacsurgery.

AdultStroke

Part11emphasizestheearlymanagementofacuteischemicstrokeinadultpatients.Itsummarizesout-of-hospitalcarethroughthefirsthoursoftherapy.Approximately795000peoplesufferaneworrepeatstrokeeachyear,andstrokeremainsthethirdleadingcauseofdeathintheUnitedStates.Byintegratingpubliceducation,911dispatch,prehospitaldetectionandtriage,hospitalstrokesystemdevelopment,andstrokeunitmanagement,significantimprovementsinstrokecarehavebeenmade.ImportantcomponentsofthestrokesystemofcarearesummarizedinPart11.

AswithSTEMIpatients,prearrivalhospitalnotificationbythetransportingEMSunithasbeenfoundtosignificantlyincreasethepercentageofpatientswithacutestrokewhoreceivefibrinolytictherapy.The2010AHAGuidelinesforCPRandECCrecommendthateveryhospitalwithanEDhaveawrittenplanthatiscommunicatedtoEMSsystemsdescribinghowpatientswithacutestrokearetobemanagedinthatinstitution.TriageofpatientswithacutestrokedirectlytodesignatedstrokecentersisanewClassIrecommendation,whichhasbeenaddedtotheStrokeAlgorithm.AnothernewClassIrecommendationisadmissionofthestrokepatienttoadedicatedstrokeunitmanagedbyamultidisciplinaryteamexperiencedinstrokecare.

Sincepublicationofthe2005AHAGuidelinesforCPRandECC,additionaldatahaveemergedextendingthetimewindowforadministrationofIVrtPAtoselectpatientswithacuteischemicstroke.TheseguidelinesnowrecommendIVrtPAforpatientswhomeettheeligibilitycriteriafortheNationalInstituteofNeurologicalDisordersandStroke(NINDS)ortheThirdEuropeanCooperativeAcuteStrokeStudy(ECASS-3)ifrtPAisadministeredbyphysiciansinthesettingofaclearlydefinedprotocolwithaknowledgeable

PediatricBasicLifeSupport

Themajorityofpediatriccardiacarrestsareasphyxial,withonlyapproximately5%to15%attributabletoVF.8,9,27,162,163Animalstudies164–166haveshownthatresuscitationfromasphyxialarrestisbestaccomplishedbyacombinationofventilationsandchestcompressions.Thishasrecentlybeenconfirmedinalargecommunitypediatricstudy,27whichnotonlyshowedthatthebestresuscitationresultsfromasphyxialarrestwerefromacombinationofventilationsandchestcompressionsbutalsothatthesmallnumberofchildrenwithasphyxialarrestwhoreceivedcompression-onlyCPRhadnobetterresultsthanthosewhoreceivednobystanderCPR.Althoughanimalstudiesandpediatricseriessupporttheimportanceofventilationforasphyxialarrest,datainadultssuggestthatchestcompressionsarecriticalforresuscitationfromVFarrest,withventilationsbeinglessimportant.Therefore

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wecontinuetosupportacombinationofventilationsandchestcompressionsforpediatricresuscitationbutemphasizethatsuddenwitnessedcardiacarrestintheadolescent,suchasmightoccurduringanathleticevent,shouldbetreatedasaVFarrest,withemphasisonchestcompressionsandearlydefibrillation.Compression-onlyCPRisencouragedforbystanderswhoarenottrainedingivingventilationsorarehesitanttodoso.

Despitetheimportanceofprovidingacombinationofventi-lationsandchestcompressionsforresuscitationofvictimsfromasphyxialarrest(includingmostchildren)asdescribedabove,aswitchtoaC-A-B(Chestcompressions,Airway,Breathing)sequencewasrecommendedforeaseofteaching.Theoreticallythisshoulddelayventilationbyamaximumofabout18seconds(lesstimeif2recuersarepresent).

Thereisagaingreatemphasison“pushhard,pushfast,”allowingthechesttocompletelyrecoilaftereachcompres-sion,minimizinginterruptionsinchestcompressions,andavoidingexcessiveventilation.Toachieveeffectivechestcompressions,rescuersareadvisedtocompressatleastonethirdtheanterior-posteriordimensionofthechest.Thiscorrespondstoapproximately11⁄2inches(4cm)inmostinfantsand2inches(5cm)inmostchildren.

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Newsectionshavebeenaddedonresuscitationofinfantsandchildrenwithasingleventricle,afteravarietyofpalliativeprocedures,andwithpulmonaryhypertension.Thereisrecognitionthatforsomeyoungvictimsofsuddendeath,nocauseofdeathisfoundonroutineautopsybutthesevictimsarefoundtohaveageneticionchanneldefect(channelopathy)thatpredisposesthemtoafatalarrhyth-mia.Itisthereforerecommendedthatyoungvictimsofasudden,unexpectedcardiacarrestshouldhaveanunre-stricted,completeautopsywhenpossiblewithappropriatepreservationandgeneticanalysisoftissue.Detailedtestingmayrevealaninheritedchannelopathythatmayalsobepresentinsurvivingfamilymembers.

NeonatalResuscitation

Theetiologyofneonatalarrestsisnearlyalwaysasphyxia.Therefore,theA-B-Csequencehasbeenretainedforresus-citationofneonatesunlessthereisaknowncardiacetiology.Assessment,SupplementaryOxygen,andPeripartumSuctioning

Whenassessinganinfant’scardiorespiratorytransitionandneedforresuscitation,thebestindicatorswerefoundtobeincreasingheartrate,effectiverespirations,andgoodtone.Pulseoximetry,withtheprobeattachedtotherightupperextremity,shouldbeusedtoassessanyneedforsupplemen-taryoxygen.StudiesdemonstratethathealthybabiesbornattermstartwithanoxygensaturationofϽ60%andwilltakeϾ10minutestoreachasaturationofϾ90%.Hyperoxiacanbetoxic,particularlytothepreterminfant.Forbabiesbornatterm,itisbesttobeginresuscitationwithroomairratherthan100%oxygen.Anysupplementaryoxygenadministeredshouldberegulatedbyblendingoxygenandair,usingoximetrytoguidetitrationoftheblenddelivered.

Theroleofperipartumsuctioninghasbeendeemphasized.Thereisnoevidencetosupportairwaysuctioninginactivebabies,eveninthepresenceofmeconium.Theavailableevidencedoesnotsupportorrefutetheroutineendotrachealsuctioningofnon-vigorousinfantsbornthroughmeconium-stainedamnioticfluid.

ChestCompressions

Therecommendedcompression-ventilationratioremains3:1becauseventilationiscriticaltoreversalofnewbornasphyxialarrestandhigherratiosmaydecreaseminuteventilation.Ifthearrestisknowntobeofcardiacetiology,ahigherratio(15:2)shouldbeconsidered.Ifepinephrineisindicated,adoseof0.01to0.03mg/kgshouldbeadministeredIVassoonaspossible.Whenusingtheendotrachealrouteitislikelythatalargerdose(0.05mg/kgto0.1mg/kg)willberequired.

PostresuscitationCare(Post-CardiacArrestCare)

Therapeutichypothermiaisrecommendedforbabiesbornneartermwithevolvingmoderatetoseverehypoxic-ischemicen-cephalopathy.Coolingshouldbeinitiatedandconductedunderclearlydefinedprotocolswithtreatmentinneonatalintensivecarefacilitiesandthecapabilitiesformultidisciplinarycare.

PediatricAdvancedLifeSupport

Thefollowingarethemostimportantchangesandreinforce-mentstorecommendationsinthe2005AHAGuidelinesforCPRandECC:

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Thereisadditionalevidencethatmanyhealthcareprovid-erscannotquicklyandreliablydeterminethepresenceorabsenceofapulseininfantsorchildren.167Thepulseassessmentisthereforeagaindeemphasizedforhealthcareproviders.Forachildwhoisunresponsiveandnotbreath-ingnormally,ifapulsecannotbedetectedwithin10seconds,healthcareprovidersshouldbeginCPR.

Moredatasupportthesafetyandeffectivenessofcuffedendotrachealtubesininfantsandyoungchildren,andtheformulaforselectingtheappropriatelysizedcuffedtubehasbeenupdated.

Thesafetyandvalueofusingcricoidpressureduringemergencyintubationhasbeenquestioned.Itisthereforerecommendedthattheapplicationofcricoidpressureshouldbemodifiedordiscontinuedifitimpedesventila-tionorthespeedoreaseofintubation.

Monitoringcapnography/capnometryisagainrecom-mendedtoconfirmproperendotrachealtube(andotheradvancedairway)positionandmaybeusefulduringCPRtoassessandoptimizequalityofchestcompressions.Theoptimalenergydoserequiredfordefibrillation(usingeitheramonophasicorbiphasicwaveform)ininfantsandchildrenisunknown.WhenshocksareindicatedforVForpulselessVTininfantsandchildren,aninitialenergydoseof2to4J/kgofeitherwaveformisreasonable;doseshigherthan4J/kg,especiallyifdeliveredwithabiphasicdefibrillator,mayalsobesafeandeffective.

Onthebasisofincreasingevidenceofpotentialharmfromhighoxygenexposureaftercardiacarrest,oncespontane-ouscirculationisrestored,inspiredoxygenshouldbetitratedtolimittheriskofhyperoxemia.

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Ethics

Thedurationofresuscitationfornewbornswithprolongedcardiacarrestwasreviewed.Inanewlybornbabywithnodetectableheartratethatremainsundetectablefor10minutes,itisappropriatetoconsiderstoppingresuscitation.Whengestation,birthweight,orcongenitalanomaliesareassoci-atedwithalmostcertainearlydeathandanunacceptablyhighmorbidityislikelyamongtheraresurvivors,resuscitationisnotindicated.

Theroleofsimulationineducationwasassessed.Thetaskforceconcludedthatalthoughitisreasonabletousesimulationinresuscitationeducation,themosteffectivemethodologiesremaintobedefined.Briefingsanddebriefingsduringlearningimproveacquisitionofcontentknowledge,technicalskills,orbehavioralskillsrequiredforeffective,saferesuscitation.

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Education

“Education,Implementation,andTeams”isanewsectioninthe2010AHAGuidelinesforCPRandECC.Majorrecom-mendationsandpointsofemphasisinthisnewsectionincludethefollowing:

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BystanderCPRdramaticallyimprovessurvivalfromcar-diacarrest,yetfarlessthanhalfofarrestvictimsreceivethispotentiallylifesavingtherapy.

MethodstoimprovebystanderwillingnesstoperformCPRincludeformaltraininginCPRtechniques,includingcompression-only(Hands-Only)CPRforthosewhomaybeunwillingorunabletoperformconventionalCPR;educatingprovidersonthelowriskofacquiringaninfectionbyperformingCPR;andspecifictrainingdirectedathelpingprovidersovercomefearorpanicwhenfacedwithanactualcardiacarrestvictim.

EMSshouldprovidedispatcherinstructionsoverthetele-phonetohelpbystandersrecognizevictimsofcardiacarrest,includingvictimswhomaystillbegasping,andtoencouragebystanderstoprovideCPRifarrestislikely.Dispatchersmayalsoinstructuntrainedbystandersintheperformanceofcompression-only(Hands-Only)CPR.BLSskillscanbelearnedequallywellwith“practicewhilewatching”(video-based)trainingasthroughlonger,tradi-tionalinstructor-ledcourses.

Toreducethetimetodefibrillationforcardiacarrestvictims,AEDuseshouldnotbelimitedonlytopersonswithformaltrainingintheiruse.However,AEDtrainingdoesimproveperformanceinsimulationandcontinuestoberecommended.

TraininginteamworkandleadershipskillsshouldcontinuetobeincludedinALScourses.

Manikinswithrealisticfeaturessuchasthecapabilitytoreplicatechestexpansionandbreathsounds,generateapulseandbloodpressure,andspeakmaybeusefulforintegratingtheknowledge,skills,andbehaviorsrequiredinALStraining.However,thereisinsufficientevidencetorecommendtheirroutineuseinALScourses.

Writtentestsshouldnotbeusedexclusivelytoassessthecompetenceofaparticipantinanadvancedlifesupport(ACLSorPALS)course(ie,thereneedstobeaperfor-manceassessmentaswell).

Formalassessmentshouldcontinuetobeincludedinresuscitationcourses,bothasamethodofevaluatingthesuccessofthestudentinachievingthelearningobjectivesandofevaluatingtheeffectivenessofthecourse.

Thecurrent2-yearcertificationperiodforbasicandad-vancedlifesupportcoursesshouldincludeperiodicassess-mentofrescuerknowledgeandskillswithreinforcementprovidedasneeded.Theoptimaltimingandmethodforthisassessmentandreinforcementarenotknownandwarrantfurtherinvestigation.

CPRpromptandfeedbackdevicesmaybeusefulfortrainingrescuersandmaybeusefulaspartofanoverallstrategytoimprovethequalityofCPRforactualcardiacarrests.

Debriefingisalearner-focused,nonthreateningtechniquetoassistindividualrescuersorteamstoreflectonandimproveperformance.Debriefingshouldbeincludedinadvancedlifesupportcoursestofacilitatelearningandcanbeusedtoreviewperformanceintheclinicalsettingtoimprovesubsequentperformance.

Systems-basedapproachestoimprovingresuscitationper-formance,suchasregionalsystemsofcareandrapidresponsesystems,maybeusefultoreducethevariabilityofsurvivalforcardiacarrest.

FirstAid

Onceagain,areviewoftheliteratureonmanytopicsrelevanttofirstaidfoundthatlittleinvestigationisbeingcarriedoutinthisfield,andmanyrecommendationshavehadtobeextrapolatedfromresearchpublishedinrelatedfields.Thefollowingarenewrecommendationsorreinforcementsofpreviousrecommendations.

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Evidencesuggeststhat,withouttraining,laypersonsandsomehealthcareprofessionalsmaybeunabletorecognizethesignsandsymptomsofanaphylaxis.Therefore,initialorsubsequentadministrationofepinephrineforanaphy-laxisbyeitherofthesegroupsmaybeproblematic.Thisissuetakesonaddedimportanceinviewoflegislationpermittingthepracticeinsomejurisdictions.

Exceptindivingdecompressioninjuries,thereisnoevi-denceofanybenefitofadministrationofoxygenbyfirstaidproviders.

Theadministrationofaspirinbyafirstaidprovidertoavictimexperiencingchestdiscomfortisproblematic.Theliteratureisclearonthebenefitofearlyadminis-trationofaspirintovictimsexperiencingacoronaryischemiceventexceptwhenthereisacontraindication,suchastrueaspirinallergyorableedingdisorder.Lessclear,however,iswhetherfirstaidproviderscanrecog-nizethesignsandsymptomsofanacutecoronarysyndromeorcontraindicationstoaspirinandwhetheradministrationofaspirinbyfirstaidprovidersdelaysdefinitivetherapyinanadvancedmedicalfacility.

Noevidenceofbenefitwasfoundforplacinganunrespon-sivevictimwhoisbreathingina“recovery”position.Studiesperformedwithvolunteersappeartoshowthatifavictimisturnedbecauseofemesisorcopioussecretions,theHAINES(HighArmINEndangeredSpine)positionisanexampleofarecoverypositionthatmayhavesometheoreticadvantages.

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Since2005considerablenewdatahaveemergedontheuseoftourniquetstocontrolbleeding.Thisexperiencecomespri-marilyfromthebattlefieldsofIraqandAfghanistan.Thereisnoquestionthattourniquetsdocontrolbleeding,butifleftontoolong,theycancausegangrenedistaltotheapplicationandsystemiccomplications,includingshockanddeath.Protocolsfortheproperuseoftourniquetstocontrolbleedingexist,butthereisnoexperiencewithcivilianuseorhowtoteachtheproperapplicationoftourniquetstofirstaidproviders.Studieshaveshownthatnotalltourniquetsarethesame,andsomemanufacturedtourniquetsperformbetterthanothersandbetterthantourniquetsthatareimprovised.

Becauseofitsimportance,theissueofspinalstabilizationwasonceagainreviewed.Unfortunatelyverylittlenewdataareavailable,anditisstillnotclearwhethersecondaryspinalcordinjuryisarealproblemandwhetherthemethodsrecommendedforspinalstabilizationormove-mentrestrictionareeffective.

Theliteratureregardingfirstaidforsnakebiteswasonceagainreviewed.Inthe2005reviewevidencewasfoundforabeneficialeffectfrompressureimmobilizationforneu-rotoxicsnakebites,butitnowappearsthatthereisabenefitevenfornon-neurotoxicsnakebites.Thechallengeisthattherangeofpressureneededundertheimmobilizationbandageappearstobecriticalandmaybedifficulttoteachorestimateinthefield.

Anewsectiononjellyfishstingshasbeenaddedandnewrecommendationsfortreatmenthavebeenmade.

Theliteratureonthefirstaidtreatmentoffrostbitewasreviewed.Therecontinuestobeevidenceofpotentialharminthawingofafrozenbodypartifthereisanychanceofrefreezing.Theliteratureismixedonthebenefitofnonsteroidalanti-inflammatoryagentsasafirstaidtreat-mentforfrostbite.Chemicalwarmersshouldnotbeusedbecausetheymaygeneratetemperaturescapableofcausingtissueinjury.

OralfluidreplacementhasbeenfoundtobeaseffectiveasIVfluidinexercise-orheat-induceddehydration.Thebestoralfluidappearstobeacarbohydrate-electrolytemixture.

TheCOIpoliciesandactionsforthe2010evidenceevaluationprocess170describedinfullinPart2ofthispublicationappliedtotheentire5-yearconsensusdevelopmentprocess—before,during,andaftertheactual2010InternationalConsensusCon-ference.Thepoliciesappliedtoallaspectsoftheevidenceevaluationprocess,includingselectionofleadersandmembersofILCORtaskforcesandwritinggroups,selectionoftopicsforworksheets,selectionofworksheetauthors,presentationanddiscussionofworksheets,developmentoffinalConsensusonSciencestatements,and,fortheAHA,creationofthe2010AHAGuidelinesforCPRandECCthatfollowinthispublication.Thepoliciesappliedtoallvolunteersandstaffinvolvedintheprocess,includingallleadersandmembersofILCORcommit-tees(ConferencePlanningCommittee,EditorialBoard,andTaskForcesforresuscitationareas),allevidenceevaluationworksheetauthors,andall2010InternationalConsensusCon-ferenceparticipants.

Asin2005,duringtheentire2010InternationalConsensusConferenceeveryparticipantusedhisorherassignednumberwhenspeakingasapresenter,panelist,moderator,orcommen-tatorfromthefloor.Forthedurationofeachspeaker’scom-ments,aslidewasdisplayedwiththespeaker’sname,institution,andanycommercialrelationshipsthespeakerhaddisclosedsothattheaudiencecouldassesstheimpacttheserelationshipsmighthaveonthespeaker’sinput.Allparticipantswereencour-agedtoraiseanyconcernswiththemoderatorsoridentifiedCOIleadsfortheconference.Dependingonthenatureoftherelationshipandtheirroleintheguidelinesprocess,participantswererestrictedfromsomeactivities(ie,leading,voting,decid-ing,writing)thatdirectlyorindirectlyrelatedtothatcommercialinterest.Althoughthefocusoftheevidenceevaluationprocesswasevaluationofthescientificdataandtranslationofthatevidenceintotreatmentrecommendationsandguidelines,atten-tiontopotentialconflictsofinterestwasomnipresentthroughouttheprocess,helpingensureevidence-basedguidelinesfreeofcommercialinfluence.

Summary

Aswemarkthe50thanniversaryofmodern-eraCPR,wemustacknowledgethat,despitemeasurableprogressaimedatitsprevention,cardiacarrest—bothinandoutofthehospital—continuestobeamajorpublichealthchallenge.Overthese50years,scientificknowledgeaboutarrestpathophysiologyandresuscitationmechanismshasin-creasedsubstantially.Inourongoingcommitmenttoensureoptimalcommunity-basedcareforallvictimsofcardiacarrest,wemustcontinuetoeffectivelytranslatethescienceofresuscitationintoclinicalcareandimprovedresuscitationoutcomes.

ConflictofInterestManagement

Throughoutthe2010evidenceevaluationprocesstheAHAandtheInternationalLiaisonCommitteeonResusciation(ILCOR)followedrigorousconflictofinterest(COI)policiestoensurethatthepotentialforcommercialbiaswasminimized.TheCOIprocesswasbasedonthesuccessfulpoliciesandactionsusedindevelopingthe2005InternationalConsensusonCPRandECCScienceWithTreatmentRecommendations.168,169In2007ILCORmodifiedtheCOImanagementpoliciestobeusedforthe2010evidenceevaluationprocess,furtherenhancingandbuildingontheprocessusedin2005.Modificationsensuredthatcommercialrelationshipswereidentifiedasearlyaspossibletoavoidpotentialconflictsbyreassigningtheroletoaparticipantwhohadnoconflictsbeforeworkbegan.TherevisionsalsotookintoaccountchangesinAHApolicies,approvedbytheAHAScienceAdvisoryandCoordinatingCommitteein2009,regard-ingrequirementsforscientificstatementandguidelinewritinggroupchairsandmembers.

Acknowledgments

Thewritinggroupgratefullyacknowledgestheextraordinarydedi-cationandcontributionsoftheAHAECCstaff,especiallyKaraRobinson,aswellasDavidBarnes,JenniferDenton,LanaGent,ColleenHalverson,JodyHundley,AliciaPederson,TanyaSemenko,andNinaTran.Inaddition,thewritinggroupacknowledgesaddi-tionaloutstandingcontributions,especiallyfromBrendaSchoolfield,andalsofromJeanetteAllison,JanetButler,HebaCostandy,CathrynEvans,PierceGoetz,andSallieYoung.

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S650CirculationNovember2,2010

Disclosures

GuidelinesPart1:ExecutiveSummary:WritingGroupDisclosures

WritingGroupMemberJohnM.Field

Employment

PennStateUniversityCOM&HeartandVascularInstitute–ProfessorofMedicineandSurgery.AHAECC

SeniorScienceEditor

MaryFranHazinski

VanderbiltUniversitySchoolofNursing—Professor;AHA

ECCProductDevelopment-SeniorScienceEditor†SignificantAHAcompensationtowrite,editandreviewdocumentssuchasthe2010AHAGuidelinesforCPRand

ECC.

MichaelR.SayreLeonChameides

EmeritusDirectorPediatricCardiology,ConnecticutChildren’sHospital;ClinicalProfessor,Universityof

Connecticut

StephenM.Schexnayder

UniversityofArkansasforMedical

Sciences–Professor/DivisionChief;AHACompensatedConsultantasAssociateSeniorScienceEditor

*Pharmacokineticsofprotonpumpinhibitors

incriticallyillchildren

None

*ContemporaryForums(nursing

conferences)

None

None

*Variousmedicallegalcasesinvolvingpediatriccriticalcare&emergencymedicine

RobinHemphill

EmoryUniversity,Dept.ofEmergencyMedicine–Associate

Professor†PaidAHAwriter

RicardoA.Samson

TheUniversityofArizona,providingclinicalcare,teaching,andresearchassociatedwithanacademicpediatric

cardiologypractice.ProfessorofPediatrics

None

None

None

None

†Consultant-American

Heart

Association-AssociateScienceEditorSalarysupportreceivedtodevote30%timeto

AHAforthedevelopmentofECC

materials

JohnKattwinkelRobertA.Berg

UofPennsylvania-Professor

Co-I,LaerdalFoundation,SarverHeartCenter(UofArizona)CardiacArrestandCPRProgramSupportGrant,2007–2009

FarhanBhanjiDianaM.CaveEdwardC.Jauch

MedicalUniversityofSouthCarolina;Emergencymedicine

physician,Stroketeamphysician,Professor

†NIH(EC)IMS-3U01NS052220(not

related)

NIHstudy,allmoneytoUniversity*NIH(Co-I)ALIASIIStudyU01NS054630NIHstudy,allmoneytoUniversity

None

None

None

None

*Member,DSMBFieldAdministrationof

StrokeTherapy–MagnesiumTrial(U01NS044364)Nomoneyinvolved

PeterJ.Kudenchuk

UniversityofWashington–ProfessorofMedicine

†NHLBIResuscitationOutcomesConsortium(PrincipalInvestigator);fundingcomesto

institution

None

*NetworkforContinuingMedicalEducation,Academyfor

HealthcareEducation,Sanofi-Aventis,Pri-Med,HoriizonCME,withhonoraria

RobertW.Neumar

UniversityofPennsylvania–AssociateProfessorof

EmergencyMedicine

†FundingSource:NIH/NINDSGrantNumber:R21NS054654FundingPeriod06/01/07to06/31/2010RoleonProject:PrincipalInvestigatorTitle:OptimizingTherapeuticHypothermiaAfterCardiacArrestDescription:Thegoalofthisprojectistoevaluatehowtheonsetanddurationoftherapeutichypothermiaaftercardiacarrestimpactssurvivalandneuroprotection

(Continued)

None

None

None

None

None

*Sanofi-Aventis,Novartis

None

†Medical-legalConsultation

MontrealChildren’sHospital,McGillUniversity;Assistant

ProfessorofPediatrics

LegacyHealthSystem,EmergencyServices,RN

None

None

None

None

None

None

None

None

None

None

None

None

None

None

None.

None

None

UniversityofVirginia—ProfessorofPediatrics

None

None

None

None

None

NoneNone

None

None

None

None

None

None

None

None

None

None

None

None

TheOhioStateUniversity-AssociateProfessor

None

None

None

None

None

None

None

None

None

None

None

None

ResearchGrant

None

OtherResearchSupportNone

Speakers’Bureau/Honoraria

None

OwnershipInterestNone

Consultant/Advisory

BoardNone

OtherNone

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Fieldetal

GuidelinesPart1:ExecutiveSummary:WritingGroupDisclosures,Continued

WritingGroupMemberMaryAnnPeberdyJeffreyM.PerlmanElizabethSinz

PennStateHersheyMedicalCenter–Professorof

AnesthesiologyandNeurosurgery*AssociateScienceEditorforAHA

AndrewH.TraversMarcD.Berg

UniversityofArizona/UniversityPhysician’sHealthcare(UPH)–Asso.Prof.ClinicalPediatricsAttendingIntensivist,

PediatricCriticalCareMedicine

JohnE.BilliBrianEigel

UniversityofMichiganMedicalSchool-ProfessorAmericanHeartAssociation–DirectorofScience,ECC

Programs

RobertW.Hickey

UniversityofPittsburgh–MD

†NIHsponsoredresearchontheeffectofcyclopentenoneprostaglandinsupon

post-ischemicbrain

None

None

NoneNone

NoneNone

NoneNone

None

None

None

EmergencyHealthServicesNS-ProvincialMedicalDirector

None

None

None

Employment

VirginiaCommonwealthUniversity-ProfessorofInternal

MedicineandEmergencyMedicine

WeillCornellMedicalCollege-ProfessorofPediatrics

*NIHGrant–Co-PI-AntimicrobialDosingin

theNIHNone

None

None

None

None

ResearchGrant

None

OtherResearchSupportNone

Part1:ExecutiveSummaryS651

Ownership

Speakers’Bureau/Honoraria

None

InterestNone

Consultant/Advisory

BoardNone

OtherNone

NoneNoneNone

NoneNoneNone

NoneNoneNone

NoneNoneNone

NoneNone

NoneNone

NoneNone

NoneNone*Occasionalexpertwitnessinmedicalmalpracticecases(1–2times/yr)

MonicaE.KleinmanMarkS.LinkLaurieJ.MorrisonRobertE.O’ConnorMichaelShusterCliftonW.Callaway

Children’sHospitalAnesthesiaFoundation:Not-for-profitfoundation–SeniorAssociateinCriticalCareMedicine

TuftsMedicalCenterAcademicMedical

Institution-AttendingPhysicianSt.MichaelHospital,clinician

NoneNoneNoneNoneNoneNone

NoneNoneNoneNoneNoneNone

NoneNoneNoneNoneNoneNone

UniversityofVirginiaHealthSystem–ProfessorandChairof

EmergencyMedicine

Self-employed;EmergencyPhysician

NoneNoneNoneNoneNoneNone

NoneNoneNoneNoneNoneNone

UniversityofPittsburghSchoolofMedicine;Associate

Professor

UPMCHealthSystem;Physician

†NHLBI-ResuscitationOutcomesConsortium*LoanofcoolingequipmentfromMedivance,Inc.,amanufacturerofhypothermiadevices

None†Coinventoronpatentsrelatedtotimingofdefibrillation.PatentslicensedtoMedtronicERS,bytheUniversityofPittsburgh.*OwnstockinAppleComputer,

Inc.

NoneNone

BrettCucchiara

UniversityofPennsylvaniaAssistantProfessorofNeurology†NIHRO1-migraineimagingresearchNone*MultipleCMEtalksatdifferent

institutions

NoneNone*Occasionallyservesasexpertwitnessformedicolegalcases

JeffreyD.Ferguson

BrodySchoolofMedicineatEastCarolinaUniversity–

AssistantProfessor

NoneNoneNoneNoneNone*Currentlyinvolvedasexpertwitnessontwopendingcases.Feestodatetotallessthan$10,000overprevious

12months

ThomasD.Rea

UniversityofWashington-AssociateProfessor†MedtronicFoundationtodevelopcommunityapproachestoimproveresuscitation.Moniestotheinstitution.†LaerdalFoundationtoevaluateoptimalapproachesforbystanderCPR.Moniesto

theinstitution.*PhilipsMedicalIncPhysioControlInc

†PhilipsMedical

andPhysioControlprovidedequipmenttosupportresearch.Equipmentwenttotheinstitution.

NoneNoneNoneNone

(Continued)

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S652CirculationNovember2,2010

GuidelinesPart1:ExecutiveSummary:WritingGroupDisclosures,Continued

WritingGroupMemberTerryL.VandenHoek

Employment

TheUniversityofChicago;AssociateProfessor

ResearchGrant

*PrincipalInvestigatorDepartmentofDefense,OfficeofNavalResearchЉProteomicDevelopmentofMolecularVitalSigns:MappingaMitochondrialInjurySeverityScoretoTriageandGuideResuscitationofHemorrhagicShockЉ9/6/04–4/31/10$885,639(currentyear)ResearchgrantawardedtotheUniversityof

Chicago

OtherResearchSupportNone

Speakers’Bureau/Honoraria

None

OwnershipInterestNone

Consultant/Advisory

BoardNone

OtherNone

ThistablerepresentstherelationshipsofwritinggroupmembersthatmaybeperceivedasactualorreasonablyperceivedconflictsofinterestasreportedontheDisclosureQuestionnaire,whichallmembersofthewritinggrouparerequiredtocompleteandsubmit.Arelationshipisconsideredtobe“significant”if(a)thepersonreceives$10000ormoreduringany12-monthperiod,or5%ormoreoftheperson’sgrossincome;or(b)thepersonowns5%ormoreofthevotingstockorshareoftheentity,orowns$10000ormoreofthefairmarketvalueoftheentity.Arelationshipisconsideredtobe“modest”ifitislessthan“significant”undertheprecedingdefinition.*Modest.†Significant.

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Ⅲ

cardiopulmonaryresuscitation

Ⅲ

emergency

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