Thursday, October 21, 2010

More on CPR-ACLS 2010

A podcast interview with blogger Tom Bouthillet and Dr. Monica Kleinman, incoming Chair of the Emergency Cardiovascular Care committee can be accessed here at MediCast and is well worth the listen if you're interested in the thinking behind the changes and how they'll affect your practice.

Here are a few points of interest mixed in with a few of my own observations:

Benchmarking. Measurement of outcomes got increased emphasis in the 2010 guidelines. The notion is that each community should know its own numbers and that these numbers should drive process improvement. We rate schools, water quality, crime rates and the like, so why not emergency cardiac care? We already have some data on community survival rates. The three regions of the US which departed from the AHA guidelines to implement Ewy's cardiocerebral resuscitation demonstrated a quantum leap in neurologically intact survival. Others, which stayed with the guidelines, showed much lower survival but with considerable variation among cities.

Post resuscitation care is another link added to the chain of survival.

The 2010 guidelines come short of adopting Ewy's cardiocerebral resuscitation protocols and therefore don't go far enough. Lay rescuers are to be taught compression only CPR but professional rescuers are stuck with the old 30:2 with only the initial sequence changed (compressions first then breathing). Thus, “best practice” falls five more years behind best evidence. In the spirit of transparency Dr. Kleinman noted that during guideline development there was considerable debate, and there was a “camp” of experts who wanted to eliminate ventilations altogether in adult cardiac arrest.

Quantitative waveform capnography. This is now in the main cardiac arrest algorithm. The beauty of this technique is its multiple uses, starting with confirmation of ETT placement, to monitoring the maintenance of ETT placement, to monitoring the quality of compressions to alerting the provider of return of spontaneous circulation.

Atropine, which began to see a diminished role in 2005, is now gone from the cardiac arrest algorithm. It maintains a role in bradycardia.

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