advanced cardiac life support update: the new ilcor...

EXTENDED ABSTRACTS FROM INVITED SPEAKERS AT THE 1ST MEDITERRANEAN CONGRESS ONEMERGENCY MEDICINE, STRESA, 2–5 SEPTEMBER 2001

Advanced cardiac life support update: the newILCOR cardiovascular resuscitation guidelines

S. HACHIMI-IDRISSI and L. HUYGHENS

Department of Critical Care Medicine and Cerebral Resuscitation Research Group, Vrije Universiteit Van Brussel,Laarbeeklaan, 101, B-1090 Brussels, Belgium

& 2002 Lippincott Williams & Wilkins.

Keywords: International liaison committee on resuscitation; guideline

INTRODUCTION

In 1974 the first American Heart Association (AHA)and Emergency Cardiac Care (ECC) standards forresuscitation were published.1 At that time only a fewof the recommended measures were based onscientific evidence, but the medical world acceptedthem as international precepts that formed the goldstandard for resuscitation care. Although they hadbeen evolved only on the basis of national experienceand requirements within the USA, they quicklyacquired medicolegal significance both within andbeyond the borders of the USA.

Since then, many additional national guidelines havebeen developed and published to replace or comple-ment the 1974 standards.1 These include publicationsfrom the AHA in 1980,2 19863 and 1992,4 from theEuropean Resuscitation Council (ERC) in 1992,5 1996 6

and 1998,7 and material from other council such asthose from Australia and Southern Africa.

In the absence of any new scientific base, all the newguidelines have included detailed advice that remainsscientifically unproved and has been justified only onclinical experience.

Against this background, the International LiaisonCommittee on Resuscitation (ILCOR) worked to produceagreed policy statements on cardiopulmonary resuscita-tion (CPR) based as much as possible on scientificallyproven material, while being aware of educationalaspects that demand simplification of algorithms.

ILCOR comprises the AHA, the ERC, the AustralianResuscitation Councils (ARC), the ResuscitationCouncil of Southern Africa (RCSA), and the Resusci-tation Council of South America (Cosejo Latinoamer-

icano de Resuscitacion; CLAR). The policy statementof ILCOR has been published in several journals andlanguages.8 Its goals are:

K to produce international guidelines supported byinternational science and developed byinternational collaboration

K to establish ILCOR as the committee responsible forco-ordinating the international science

K to determine evidence-based scienceK to review and revise recommendations from past

conferences, based on scientific evidenceK to review and recommend changes in methods for

teaching the knowledge and skills of ECC.

Each guideline was graded according to the strength ofthe supporting evidence as being definitely effective(class I), probably effective (class IIa), possibly effective(class IIb), not useful (class III), or of indeterminatebenefit (because of insufficient evidence).

The ERC has closely followed the ILCOR statement,which offers an authoritative European model. TheERC Advanced Life Support Working Group hasconsidered this document and has recommendedsome changes in the guidelines that will be suitablefor European practice.9

GUIDELINES CHANGES

Basic life support (Fig. 1)

Significant changes in the basic life support (BLS) forcardiac arrest guidelines include the following:

K The carotid pulse check should be ‘de-emphasized’for lay persons and the expression ‘look for signs of

& 2002 Lippincott Williams & Wilkins

EUROPEAN JOURNALOFEMERGENCYMEDICINE, 2002, 9,193^202

circulation for not more than 10 s’ should be usedinstead (class IIa). Several studies have shown that farmore than 10 s are required to diagnose reliably thepresence or absence of a carotid pulse,11–13 and evenwith prolonged palpation significant errors occur.14

K In a one-person rescue situation in which there isnot likely to be ventricular fibrillation (VF) (e.g.submersion, poisoning, trauma, respiratory arrest),the rescuer should perform CPR for 1 min beforealerting the emergency medical system (EMS) (classindeterminate).

K A smaller tidal volume (400–600 ml) isrecommended by the ERC15 in order to reducegastric inflation,16 whilst the AHA recommended avolume between 800 and 1200 ml,17 as withoutoxygen supplementation suboptimal oxygenationmay occur.18 Therefore, as a compromise, it isrecommended that for adult resuscitation eachrescue breath (without oxygen supplementation)should deliver a volume of 10 ml/kg, whichapproximates to 700–1000 ml for an average maleadult (class IIb). This should be delivered slowlyover about 2 s and the rescuer should take a deepbreath before each ventilation.19

K In one- and two-person rescue situations, thecompression to ventilation ratio should be 15:2until the endotracheal tube is secured (class IIb).

Fig. 1. Algorithm for adult basic life support. Adapted withpermission from reference 10 (& ERC 2001)

BLS Check circulation Chest compressions

FailSucceed

Attempt ventilation

Check breathing

Check mouth

Open airway

Unconscious

Fig. 2. Algorithm for the management of choking in adults.Adapted with permission from reference 10 (& ERC 2001)

Fig. 3. Algorithm for the use of automated externaldefibrillation. Adapted with permission from reference 24(& ERC 2001)

194 HACHIMI-IDRISSI andHUYGHENS

EUROPEAN JOURNAL OF EMERGENCY MEDICINE (2002) 9(2)

The rationale behind this is that, when cardiaccompressions are uninterrupted, the coronaryperfusion pressure is higher after 15compressions.20

K Medical dispatchers (class IIa) should teach chestcompression without ventilation, rather than no CPR.

Relief of foreign body airway obstruction(Fig. 2)

K Lay rescuers should be taught standard chestcompression as the method of removing a foreign

body in the airway of an unresponsive patient(class IIb).

K Several authorities have recommendedsimplification of the techniques to be usedin a choking victim in order to bring aboutbetter acquisition and retention of skills,21,22

since the risk of death from myocardial infarctionis greater than that of dying from choking.23

Therefore, it is recommended for lay rescuersthat, if a victim of choking is or becomesunconscious, a modified sequence of BLS shouldbe applied rather than backslaps and abdominalthrusts (Fig. 2).

Potential reversible causesthe "4 h's and 4 t's":¦ hypoxia¦ hypovolaemia¦ hypo/hyperkalaemia & metabolic disorders¦ hypothermia

¦ tension pneumothorax¦ tamponade¦ toxic/therapeutic disorders¦ thrombo-embolic & mechanical obstruction

During CPRCorrect reversible causesIf not already:¦ check: electrodes, paddle position, contact¦ attempt / verify airway, O2, i.v. access¦ give adernaline / 3 min¦ consider buffers antiarrhythmics atropine / pacing

CPR 3 min*1 min if immediately

after defibrillation

non VF/VT

CPR 1 min

Defibrillate X 3as necessary

VF/VT

± check pulse

Assessrhythm

Attachdefib-monitor

Precordial thumpif appropriate

BLS Algorithmif appropriate

Cardiac arrest

Fig. 4. Universal advanced life support algorithm. Adapted with permission from reference 9 (& ERC 2001)

NEWILCORCARDIOVASCULARRESUSCITATIONGUIDELINES 195


Automated external defibrillation (Fig. 3)

K Delivery of BLS has been revised according to thenew ERC BLS guidelines. After identifying theabsence of normal breathing, two initial rescuebreaths are delivered7; this was stated in order toachieve uniformity between the automated externaldefibrillation (AED) and the BLS protocols.

K The carotid pulse check is no longer included in theprotocol for lay rescuers. Lay rescuers will now onlycheck for signs of circulation for no more than 10 s.Health care providers should continue to perform acarotid pulse check in addition to the other signs ofcirculation; this should take no longer than 10 s.11–13

K Professional healthcare providers in a witnessed ormonitored arrest may perform a single precordialthump before the defibrillator is attached.25

K When ‘no shock is indicated’ or immediately after aseries of three shocks, CPR should be given for1 min. In the 1998 guidelines 7 the duration of CPRwas 3 min after ‘no shock indicated’, except whenthe massage followed a successful defibrillation,when it was 1 min. This change was made tosimplify the algorithm and to improve theacquisition and retention of skills.

K If the AED protocol is to be used by advanced lifesupport providers, adrenaline should be administeredevery 2–3 min, rather than during each loop cycle ofCPR, which lasts only 1 min (Fig. 3).

Fig. 5. Algorithm for the management of bradycardia (including rates inappropriately slow for the haemodynamic state).AV, atrioventricular; BP, blood pressure. Adapted with permission from reference 9 (& ERC 2001)



Adult advanced life support (Fig. 4)

Significant changes in the advanced cardiac lifesupport (ACLS) for cardiac arrest guidelines includethe following:

K The energy level and sequence of shocks isunchanged. Biphasic energies of equivalent levelare acceptable. The importance of earlydefibrillation is strongly emphasized (class I).26,27

K High dose adrenaline is no longer recommended(indeterminate for routine use, and class IIb if lowdose failed).28,29

K Vasopressin 40 U (one dose only) is an acceptablealternative to adrenaline in VF/pulselessventricular tachycardia (VT) refractory to the firstthree shocks (class IIb).30,31

K Amiodarone is an acceptable alternativeto lignocaine in shock-refractory VF/VT(class IIb).32–35

K Lignocaine 36–42 and procainamide 43 (class IIb) arealternatives if amiodarone is not available, butshould not be given in addition to amiodarone.

K Magnesium (8 mmol) is recommended forrefractory VF if there is a suspicion ofhypomagnesaemia (class IIb).44

Fig. 6. Algorithm for the management of atrial fibrillation. Adapted with permission from reference 9 (& ERC 2001)



K Bretylium is no longer recommended.45,46

K Evidence supporting the use of lignocaine forshock-refractory VF has been downgraded to‘class indeterminate’ 38,42

.

K Amiodarone is the drug of choice for stablewide-complex tachycardia in patients withimpaired cardiac function, while procainamidecan be used for those with normal function(class IIb).47,48

K Tracheal intubation remains the optimal method ofsecuring the airway. However, this requires skills,and misplaced or displaced tracheal tubes havebeen reported. The new guidelines 9 emphasize theneed to confirm the accuracy of the tube placement

in perfusing rhythm by quantitative and qualitativemeasurement of the end-tidal CO2, or byoesophageal detector, in addition to the routineclinical methods (class IIb). With a non-perfusingrhythm, the oesophageal detector is a more reliableway of confirming accurate tube placement.

K Training in the use of alternative airways, such aslaryngeal masks and combitubes, should beencouraged (class IIa).

K All caregivers responsible for BLS should betrained in the use of bag-valve-mask ventilation(class IIa).

K Once the patient’s airway is secured, chestcompression should continue uninterrupted at a

Fig. 7. Algorithm for the management of narrow complex tachycardia (presumed supraventricular tachycardia). WPW,Wolff–Parkinson–White. Adapted with permission from reference 9 (& ERC 2001)



rate of 100/min and ventilation should becontinued at approximately 12 breaths/min.Ventilation does not need to be synchronized withchest compression as uninterrupted chest

compressions result in higher coronary perfusionpressures.20

K Other circulatory adjuncts are approved asalternatives to standard external chest

Fig. 8. Algorithm for the management of broad complex tachycardia. Adapted with permission from reference 9 (& ERC2001)



compressions,49 including active compression–decompression (ACD),50–54 interposed abdominalcompression (IAC) CPR,55,56 vest CPR,57–59

mechanical (piston) CPR,60 direct cardiac massageCPR 61–63 and impedance threshold valve CPR.64,65

All these techniques are defined as class IIb.K The sequence of the ERC bradycardia algorithm has

been slightly modified. Isoprenaline is no longerrecommended; if external pacing is not available, alow dose adrenaline infusion is recommendedinstead (Fig. 5).

K Patients with atrial fibrillation or flutter are placedinto one of three risk groups on the basis of theheart rhythm and the presence of additional signsand symptoms. If the patient is at high risk,electrical cardioversion should be attempted afterheparinization (Fig. 6).

K If the patient is pulseless in association with anarrow complex tachycardia with a rate greaterthan 250/min, cardioversion should be attempted;otherwise, vagal manoeuvres should be tried first.Adenosine is the drug of first choice (class IIa)(Fig. 7).

K If there is no pulse, then the VF algorithmshould be followed. If the patient displaysadverse signs or the rhythm is unresponsive todrugs (amiodarone or lignocaine), electricalcardioversion should be attempted (Fig. 8).

CONCLUSIONS

Although some of their suggestions are controversial,these guidelines offer the best consensus on cardiacarrest and pre-arrest management from expertsaround the world. Therefore they should be readand considered by anyone managing or teachingadult cardiac arrest.

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