First Aid

2010 Guideline: New in 2010 is the recommendation that if symptoms of anaphylaxis persist despite epinephrine administration, first aid providers should seek medical assistance before administering a second dose of epinephrine. However, if advanced medical assistance is not available and symptoms of anaphylaxis persist after a few minutes, a second dose of a prescribed epinephrine auto-injector should be given.  Explanation: The diagnosis of anaphylaxis can be a challenge, even for professionals, and excessive epinephrine administration may produce complications if given to individuals who do not have anaphylaxis.

 2010 Guideline: First aid providers should activate the EMS system first for anyone with chest discomfort. While waiting for EMS to arrive, first aid providers should advise the person to chew one adult (non–entericcoated) or two low-dose “baby” aspirins if the person has no history of allergy to aspirin and no recent gastrointestinal bleeding or other contraindications.  Explanation: Aspirin is beneficial if persistent chest discomfort is due to a heart attack (or acute coronary syndrome). It can be very difficult even for professionals to determine whether chest discomfort is of cardiac origin. The administration of aspirin must therefore never delay EMS activation.

 2010 Guideline: The routine use of hemostatic (clotting) agents to control bleeding as a first aid measure by first aid providers is not recommended at this time.  Explanation: Despite the fact that a number of hemostatic agents have been effective in controlling bleeding, their use is not recommended as a routine first aid method of bleeding control because of significant variability in effectiveness and the potential for adverse effects.

 2010 Guideline: For snakebites: Applying a pressure immobilization bandage with a pressure between 40 and 70 mm Hg in the upper extremity and between 55 and 70 mm Hg in the lower extremity around the entire length of the bitten extremity is an effective and safe way to slow lymph flow and therefore the dissemination of venom.  Snugness is adequate if the bandage is comfortably tight and a finger can pass easily, but not loosely, under the bandage.  Explanation: Effectiveness of pressure immobilization has now also been demonstrated for bites by other venomous American snakes.

 2010 Guideline: For jellyfish stings: To inactivate venom load and prevent further envenomation, jellyfish stings should be liberally washed with vinegar (4% to 6% acetic acid solution) as soon as possible and for at least 30 seconds.  After the nematocysts are removed or deactivated, the pain from jellyfish stings should be treated with hot water immersion when possible.  Explanation: A number of topical treatments have been used, but a critical evaluation of the literature shows that vinegar is most effective for inactivation of the nematocysts. Immersion with water, as hot as tolerated for about 20 minutes, is most effective for treating the pain. 

 

Basic Life Support

2010 Guideline:  A change in the basic life support (BLS) sequence of steps for trained rescuers from A-B-C (Airway, Breathing, Chest compressions) to “C-A-B” (Chestcompressions, Airway, Breathing) for adults and pediatric patients (children and infants, excluding newborns).  Also applies to BLS for healthcare providers.  Explanation: In the majority of cardiac arrests, the critical initial elements of CPR are chest compressions and early defibrillation.  In the C-A-B sequence, chest compressions will be initiated sooner and ventilation only minimally delayed until completion of the first cycle of chest compressions.  The A-B-C sequence could be a reason why fewer than a third of people in cardiac arrest receive bystander CPR. A-B-C starts with the most difficult procedures: opening the airway and delivering rescue breaths.

2010 Guideline: “Look, Listen and Feel” has been removed from the BLS algorithm.  Also applies to BLS for healthcare providers.  Explanation: Performance of “Look, Listen and Feel,” is inconsistent and time consuming.

 2010 Guideline:    :  AAC C   A compression rate of at least 100/min.  Also applies to BLS for healthcare providers.  Explanation: The number of chest compressions delivered per minute during CPR is an important determinant of return of spontaneous circulation (ROSC) and survival with good neurologic function. In most studies, delivery of more compressions during resuscitation is associated with better survival, and delivery of fewer compressions is associated with lower survival.

2010 Guideline: The new recommendation for chest compression depth: push down on the adult breastbone at least 2 inches (5 cm).  Also applies to BLS for healthcare providers.  Explanation: Compressions generate critical blood flow and oxygen and energy delivery to the heart and brain. Rescuers often do not push the chest hard enough.   

2010 Guideline:  If a bystander is not trained in CPR, the bystander should provide Hands-Only™ (compression-only) CPR for the adult victim who suddenly collapses, with an emphasis to “push hard and fast” on the center of the chest, or follow the directions of the EMS dispatcher. All trained lay rescuers should, at a minimum, provide chest compressions for victims of cardiac arrest. In addition, if the trained lay rescuer is able to perform rescue breaths, compressions and breaths should be provided in a ratio of 30 compressions to 2 breaths.  Explanation: Hands-Only (compression-only) CPR is easier for an untrained rescuer to perform and can be more readily guidedby dispatchers over the telephone. In addition, survival rates from cardiac arrests of cardiac etiology are similar with either Hands-Only CPR or CPR with both compressions and rescue breaths. However, for the trained lay rescuer who is able, the recommendation remains for the rescuer to perform both compressions and ventilations.

2010 Guideline: The new guidelines more strongly recommend that dispatchers instruct untrained lay rescuers to provide Hands-Only CPR for adults who are unresponsive, with no breathing or no normal breathing.  Dispatchers should provide instructions in conventional CPR for victims of likely asphyxial arrest (such as drowning).  Explanation:       HHHHHH Compressions-only bystander CPR substantially improves survival after adult out-of-hospital cardiac arrests compared with no bystander CPR.  Other studies of adults with cardiac arrest treated by lay rescuers showed similar survival rates among victims receiving Hands-Only CPR versus those receivingconventional CPR.  It is easier for dispatchers to instruct untrained rescuers to perform Hands-Only CPR than conventional CPR for adult victims, so the recommendation is now stronger for them to do so, unless the victim is likely to have had an asphyxial arrest.

 

Healthcare Provider BLS

 2010 Guideline:  The new guidelines do not recommend routine use of cricoid pressure in cardiac arrest.  Explanation:  Cricoid pressure can prevent gastric inflation and reduce the risk of regurgitation and aspiration during bag-mask ventilation, but it may also impede ventilation. Seven randomized studies showed that cricoid pressure can delay or prevent the placement of an advanced airway and some aspiration can still occur despite application of cricoid pressure. In addition, it is difficult to appropriately train rescuers in use of the maneuver. 

 

Electrical Therapies

  2010 Guideline:  If one is available, the rescuer should use a pediatric dose-attenuator system for attempted defibrillation of children 1 to 8 years of age with an AED. If the rescuer does not have an AED with a pediatric doseattenuator system, the rescuer should use a standard AED. For infants (<1 year of age), a manual defibrillator is preferred. If a manual defibrillator is not available, an AED with pediatric dose attenuation is desirable. If neither is available, an AED without a dose attenuator may be used.  Explanation:  The lowest energy dose for effective defibrillation in infants and children is not known. The upper limit for safe defibrillation is also not known, but doses >4 J/kg (as high as 9 J/kg) have effectively defibrillated children and animal models of pediatric arrest with no significant adverse effects.  Automated external defibrillators with relatively high-energy doses have been used successfully in infants in cardiac arrest, with no clear adverse effects. 

 

Advanced Cardiovascular Life Support (ACLS)

 2010 Guideline:  Continuous quantitative waveform capnography is now recommended for intubated patients throughout the peri-arrest period. When quantitative waveform capnography is used for adults, applications now include recommendations for confirming tracheal tube placement and for monitoring CPR quality and detecting return of spontaneous circulation based on end-tidal carbon dioxide (Petco2) values.  Explanation:  Continuous waveform capnography is the most reliable method of confirming and monitoring correct placement of an endotracheal tube. Because blood must circulate through the lungs for CO2 to be exhaled and measured, capnography can also serve as a physiologic monitor of the effectiveness of chest compressions and to detect return of spontaneous circulation. Ineffective chest compressions (due to either patient characteristics or rescuer performance) are associated with a low Petco2. Falling cardiac output or re-arrest in the patient with return of spontaneous circulation also causes a decrease in Petco2. In contrast, return of spontaneous circulation may cause an abrupt increase in Petco2.

2010 Guideline:  The conventional ACLS Cardiac Arrest Algorithm has been simplified and streamlined to emphasize the importance of high-quality CPR. The new guidelines include a new circular algorithm.  Explanation:  Before 2005, ACLS courses assumed that excellent CPR was provided, and, therefore, focused mainly on added interventions, such as manual defibrillation, drug therapy, and advanced airway management, as well as alternative and additional management options for special resuscitation situations. Although adjunctive drug therapy and advanced airway management are still part of ACLS, in 2005 the emphasis in advanced life support (ALS) returned to the basics, with an increased emphasis on what is known to work: high quality CPR. While continuing this emphasis, the 2010 guidelines note that CPR is ideally guided by physiologic monitoring and includes adequate oxygenation and early defibrillation, while the ACLS provider assesses and treats possible underlying causes of the arrest. There is no definitive clinical evidence that early intubation or drug therapy improves neurologically intact survival to hospital discharge. 

2010 Guideline:  Atropine is no longer recommended for routine use in the management of pulseless electrical activity (PEA)/asystole. Adenosine is recommended in the initial diagnosis and treatment of stable, undifferentiated regular, monomorphic widecomplex tachycardia (this is also consistent in ACLS and PALS recommendation).   Explanation:   Evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit. On the basis of new evidence of safety and potential efficacy, adenosine can now be considered as recommended.   

2010 Guideline:   Post–Cardiac Arrest Care is a new section in the 2010 guidelines. To improve survival for victims of cardiac arrest who are admitted to a hospital after return of spontaneous circulation, a comprehensive, structured, integrated, multidisciplinary system of post–cardiac arrest care should be implemented in a consistent manner. Treatment should include cardiopulmonary and neurologic support, as well as therapeutic hypothermia and percutaneous coronary interventions (PCIs), when indicated. An electroencephalogram for the diagnosis of seizures should be performed with prompt interpretation as soon as possible and should be monitored frequently or continuously in comatose patients after return of spontaneous circulation.  Explanation:  Since 2005, two nonrandomized studies with concurrent controls and other studies using historic controls have indicated the possible benefit of therapeutic hypothermia after in-hospital cardiac arrest and out-of-hospital cardiac arrest with PEA/asystole as the presenting rhythm. Organized post–cardiac arrest care with an emphasis on multidisciplinary programs that focus on optimizing hemodynamic, neurologic, and metabolic function may improve survival to hospital discharge among victims who achieve ROSC after cardiac arrest either in or out of hospital. 

Pediatric Advanced Life Support

2010 Guideline:  Specific resuscitation guidance has been added for management of cardiac arrest in infants and children with single-ventricle anatomy, Fontan or hemi-Fontan/bidirectional Glenn physiology, and pulmonary hypertension.  Explanation: Specific anatomical variants with congenital heart disease present unique challenges for resuscitation.

2010 Guideline:  Although there have been no published results of prospective randomized pediatric trials of therapeutic hypothermia, based on adult evidence, therapeutic hypothermia (to 32°C to 34°C) may be beneficial for adolescents who remain comatose after resuscitation from sudden witnessed out-of hospital VF cardiac arrest. Therapeutic hypothermia (to 32°C to 34°C) may also be considered for infants and children who remain comatose after resuscitation from cardiac arrest.  Explanation: Additional adult studies have continued to show the benefit of therapeutic hypothermia for comatose patients after cardiac arrest, including those with rhythms other than VF. Pediatric data are needed.

2010 Guideline:  The new guidelines have added this topic. When a sudden, unexplained cardiac death occurs in a child or young adult, obtain a complete past medical and family history (including a history of syncopal episodes, seizures, unexplained accidents/drowning, or sudden unexpected death at <50 years of age) and review previous ECGs. All infants, children, and young adults with sudden, unexpected death should, where resources allow, have an unrestricted complete autopsy, preferably performed by a pathologist with training and experience in cardiovascular pathology. Tissue should be preserved for genetic analysis to determine the presence of channelopathy.  Explanation: There is increasing evidence that some cases of sudden death in infants, children, and young adults may be associated with genetic mutations that cause cardiac ion transport defects known as channelopathies. These can cause fatal arrhythmias, and their correct diagnosis may be critically important for living relatives.

2010 Guideline:   Suctioning immediately after birth should be reserved for babies who have an obvious obstruction to spontaneous breathing or require positive pressure ventilation.  Explanation: There is no evidence that active babies benefit from airway suctioning, even in the presence of meconium, and there is evidence of risk associated with this suctioning. The available evidence does not support or refute the routine endotracheal suctioning of depressed infants born through meconium stained amniotic fluid.

2010 Guideline:   The recommended compression-to-ventilation ratio for newborns remains 3:1. If the arrest is known to be of cardiac etiology, a higher ratio (15:2) should be considered.  Explanation: The optimal compression-to-ventilation ratio remains unknown. The 3:1 ratio for newborns facilitates provision of adequate minute ventilation, which is considered critical for the vast majority of newborns who have an asphyxial arrest.  The consideration of a 15:2 ratio (for 2 rescuers) recognizes that newborns with a cardiac etiology of arrest may benefit from a higher compression-to-ventilation ratio.

2010 Guideline:   There is increasing evidence of benefit of delaying cord clamping for at least 1 minute in term and preterm infants not requiring resuscitation. There is insufficient evidence to support or refute a recommendation to delay cord clamping in babies requiring resuscitation.

 

Ethical Issues

2010 Guideline:   In adult post–cardiac arrest patients treated with therapeutic hypothermia, it is recommended that clinical neurologic signs, electrophysiologic studies, biomarkers, and imaging be performed where available at 3 days after cardiac arrest. Currently, there is limited evidence to guide decisions regarding withdrawal of life support. The clinician should document all available prognostic testing 72 hours after cardiac arrest treated with therapeutic hypothermia and use best clinical judgment based on this testing to make a decision to withdraw life support when appropriate.  Explanation: On the basis of the limited available evidence, potentially reliable prognosticators of poor outcome in patients treated with therapeutic hypothermia after cardiac arrest include bilateral absence of N20 peak on somatosensory evoked potential more than or equal to 24 hours after cardiac arrest and the absence of both corneal and pupillary reflexes more than or equal to 3 days after cardiac arrest. Limited available evidence also suggests that a Glasgow Coma Scale Motor Score of 2 or less at day 3 after sustained return of spontaneous circulation and presence of status epilepticus are potentially unreliable prognosticators of poor outcome in post-cardiac arrest patients treated with therapeutic hypothermia. Similarly, recovery of consciousness and cognitive functions is possible in a few post-cardiac arrest patients treated with therapeutic hypothermia despite bilateral absent or minimally present N20 responses of median nerve somatosensory evoked potentials, which suggests they may be unreliable as well. The reliability of serum biomarkers as prognostic indicators is also limited by the relatively few patients who have been studied. 

 

 

 

Since 2005, two nonrandomized studies with conc

controls and other studies using historic controls have

indicated the possible benefit of therapeutic hypothermia after

in-hospital cardiac arrest and out-of-hospital cardiac arrest

with PEA/asystole as the presenting rhythm. Organized post–

cardiac arrest care with an emphasis on multidisciplinary

programs that focus on optimizing hemodynamic, neurologic,

and metabolic function may improve survival to hospital

discharge among victims who achieve ROSC after cardiac

arrest either in or out of hospital. 

   

 

     

  

 

cardiopulmonary and neurologic support, as well as

therapeutic hypothermia and percutaneous coronary

interventions (PCIs), when indicated. An

electroencephalogram for the diagnosis of seizures

should be performed with prompt interpretation as

soon as possible and should be monitored frequently

or continuously in comatose patients after return of

spontaneous circulation. 

 

 

Evidence suggests that the routine use of atropine during PEA

or asystole is unlikely to have a therapeutic benefit. On the

basis of new evidence of safety and potential efficacy,

adenosine can now be considered as recommended. 

 

 

 

 

Evidence suggests that the routine use of atropine during PEA

or asystole is unlikely to have a therapeutic benefit. On the

basis of new evidence of safety and potential efficacy,

adenosine can now be considered as recommended. 

 

 

Atropine is no longer recommended for routine use

in the management of pulseless electrical activity

(PEA)/asystole. Adenosine is recommended in the

initial diagnosis and treatment of stable,

undifferentiated regular, monomorphic widecomplex

tachycardia (this is also consistent in ACLS

and PALS recommendations). 

 

 

 

 

 

Before 2005, ACLS courses assumed that excellent CPR was

provided, and, therefore, focused mainly on added

interventions, such as manual defibrillation, drug therapy, and

advanced airway management, as well as alternative and

additional management options for special resuscitation

situations. Although adjunctive drug therapy and advanced

airway management are still part of ACLS, in 2005 the

emphasis in advanced life support (ALS) returned to the 

 

 

The conventional ACLS Cardiac Arrest Algorithm

has been simplified and streamlined to emphasize

the importance of high-quality CPR. The new

guidelines include a new circular algorithm. 

 

 

Continuous waveform capnography is the most reliable

method of confirming and monitoring correct placement of an

endotracheal tube. Because blood must circulate through the

lungs for CO2 to be exhaled and measured, capnography can

also serve as a physiologic monitor of the effectiveness of

chest compressions and to detect return of spontaneous

circulation. Ineffective chest compressions (due to either

patient characteristics or rescuer performance) are associated

with a low Petco2. Falling cardiac output or re-arrest in the

patient with return of spontaneous circulation also causes a

decrease in Petco2. In contrast, return of spontaneous

circulation may cause an abrupt increase in Petco2

  

 

Continuous quantitative waveform capnography is

now recommended for intubated patients throughout

the peri-arrest period. When quantitative waveform

capnography is used for adults, applications now

include recommendations for confirming tracheal

tube placement and for monitoring CPR quality and

detecting return of spontaneous circulation based on

end-tidal carbon dioxide (Petco2) values. 

 

If one is available, the rescuer should use a ped

dose-attenuator system for attempted defibrillation

of children 1 to 8 years of age with an AED. If the

rescuer does not have an AED with a pediatric doseattenuator

system, the rescuer should use a standard

AED. For infants (<1 year of age), a manual

defibrillator is preferred. If a manual defibrillator is

not available, an AED with pediatric dose

attenuation is desirable. If neither is available, an

AED without a dose attenuator may be used. 

 

 

   Explanation:                   

Explanation:  

The new guidelines more strongly recommend that

dispatchers instruct untrained lay rescuers to provide

Hands-Only CPR for adults who are unresponsive,

with no breathing or no normal breathing.

Dispatchers should provide instructions in

conventional CPR for victims of likely asphyxial

arrest (such as drowning). 

 

Hands-Only CPR or CPR with both compressions

 

 

breaths. However, for the trained lay rescuer who is able, the

recommendation remains for the rescuer to perform both

compressions and ventilations 

 

 Expla

 

center of the chest, or follow the directions of the

EMS dispatcher. All trained lay rescuers should, at

a minimum, provide chest compressions for victims

of cardiac arrest. In addition, if the trained lay

rescuer is able to perform rescue breaths,

compressions and breaths should be provided in a

ratio of 30 compressions to 2 breaths. 

  

 

 

 

 

The new recommendation for chest compression

depth: push down on the adult breastbone at least

inches (5 cm

Also applies to BLS for healthcare providers.  Explanation:     Explanation:     Explanation:  Explanation: Explanation:  Explanation:  Explanation:  Explanation:  Explanation:   Explanation:   Explanation:   Explanation:   Explanation:   Explanation:  Continuous waveform c Explanation:   Explanation:   Explanation:   Explanation:   Explanation: