Wednesday, August 24, 2011

Tutorials in the Tetons 2011---ACLS update

Mountain view from lobby of conference center

Dr. Gordon Ewy, Professor of Cardiology at the University of Arizona and pioneer in CPR and emergency cardiac care, presented an update. As I have noted from past attendance at this course Dr. Ewy has been years---about a decade in fact---ahead of the American Heart Association. I also said when blogging last year's conference:

I'm usually a strong advocate for guideline based care. Almost all the studies I've examined on the effects of guideline adherence show outcomes to be improved. There's one notable exception: the AHA guidelines for CPR and emergency cardiac care.

Dr. Ewy made many of the same points this year as last. The new emphasis this year was a solidification of data showing improved outcomes with his method compared to guideline based BLS and ACLS as well as expanded discussion of the post resuscitation bundle. By the way, several years ago Dr. Ewy gave the method a new name: cardiocerebral resuscitation (CCR), reflecting the de-emphasis on rescue breathing and the improved brain outcomes.

When I blogged this conference last year the 2010 ACLS guidelines were not out. Those guidelines, published a few months later, were influenced by Ewy's work and incorporated some needed changes but didn't go far enough.

So let's see how Ewy's CCR compares with AHA's BLS and ACLS.

AHA 2010: Rescue breathing remains in the guidelines for trained rescuers but with a change in sequence (CAB instead of ABC) with hands-only CPR “encouraged” but for lay rescuers only.
CCR: Rescue breathing considered harmful and eliminated for all rescuers.

ACLS (in the field)
AHA 2010: Rescue breathing (CAB, 30:2 ratio) continues until advanced airway; “consider” advanced airway early on but timing of such airway open to clinical judgment.
CCR: Passive O2 administration via NRB mask and oral airway; no rescue breathing; no advanced airway unless failure of ROSC after at least three cycles of 200 compressions.

AHA 2010: Analyze rhythm and shock if indicated, as soon as device connected.
CCR: Analyze and shock only after 200 compressions (circulatory phase, see below).

Caveats: This method applies only to adult victims of suspected primary cardiac arrest. Children and those whose arrest is suspected clinically to be of respiratory etiology would undergo guideline based resuscitation. Delay in the use of the AED applies mainly to emergency medical personnel responding in the field, as these are patients in the circulatory phase of arrest (5 minutes down time or greater). Early use of the defibrillator, according to the guidelines, would still apply to patients believed to be in the electrical phase, e.g. those arresting in the hospital or whose arrest is witnessed in a public place where an AED is on site and immediately available.

For a discussion of the three phases of arrest see here.

For a nice summary of CCR the full text of this article is worth obtaining.

CCR has been made the official protocol in four regions of the country: greater Phoenix, greater Tucson, a region in Wisconsin and greater Kansas City. These four areas have demonstrated striking improvements in neurologically intact survival over multiple other communities that use guideline based protocols.

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