New CPR Guide Sets Compression Limits, Scratches Vasopressin
By Shannon Aymes
From Circulation
New guidelines on cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) set upper limits on chest compression rate and depth, add naloxone to the care of suspected opioid abusers, and remove vasopressin from the advanced cardiac life support (ACLS) algorithm.
Vitals Key clinical point: The percentage of nonmedical use of prescription opioids declined during the last decade, but the prevalence of use disorders, the frequency of abuse, and related mortality all increased. Major finding: The 1-year prevalence of opioid use disorders rose from 0.6% to 0.9%, that of high-frequency use increased from 0.3% to 0.4%, and that of opioid-related deaths increased from 4.5 per 100,000 to 7.8 per 100,000. Data source: An analysis of time trends in prescription opioid use, based on two nationally representative data sets involving 472,200 adults. Disclosures: The Substance Abuse and Mental Health Services Administration, the National Institute on Drug Abuse, and the US Food and Drug Administration (FDA) sponsored the study. Dr Han reported having no relevant disclosures; an associate reported owning stock in General Electric, 3M Company, and Pfizer. |
The American Heart Association (AHA) published its revised guidelines October 15 in Circulation.1 The AHA released its previous guidelines in 2010.2
“When everyone knows their role, knows CPR, and works together, we can dramatically improve cardiac arrest victims’ chances of survival,” Dr Mark Creager, AHA president and director of the Heart and Vascular Center at Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, said in a statement.
The 2015 guidelines’ new recommendations include the following:
Resuscitation pathways. The guidelines note that the resuscitation pathways are very different for patients who experience cardiac arrest present in either a hospital setting (IHCA) or out-of-hospital setting (OHCA). In an OHCA, the patient depends on lay rescuers to not only recognize the situation but also call for help, initiate CPR, and, if available, administer defibrillation until emergency medical personnel arrive. However, IHCA involves prevention of cardiac arrest and smooth delivery of care in a multidisciplinary setting.
Layperson CPR. Untrained lay rescuers should provide compression-only CPR for OHCA. Trained lay rescuers who are able to provide rescue breaths should begin CPR with compressions followed by breaths at a ratio of 30 compressions to two breaths. Compression-only CPR is easier to perform for untrained lay rescuers, the guidelines note, and survival rates are similar using CPR with or without rescue breaths in adult cardiac arrest with a cardiac etiology.
Compression rate and depth. The new guidelines set upper limits on chest compression depth and heart rate, recommending a compression rate of 100-120 compressions per minute with a depth of at least 2 inches, not to exceed 2.4 inches in adults.
Social media dispatching. Despite limited evidence, the guideline authors said that it may be reasonable for communities to use social media technologies to alert lay rescuers with mobile phones about nearby OHCA cases.
Naloxone and opioid addiction. Also new to the guidelines is the recommended use of naloxone for patients with suspected or known opioid addiction by appropriately trained lay rescuers or basic life support (BLS) providers.
CPR training. The guidelines highlight several changes to simplify health care provider training in CPR. For example, trained rescuers can simultaneously perform some tasks to reduce the time to initiate chest compressions. Likewise, in a team of trained rescuers, multiple steps—such as activating the emergency response system, chest compression, ventilation, and defibrillator retrieval—can be accomplished simultaneously.
High-quality CPR. The guidelines focus on emphasizing high-quality CPR with adequate compression rate and depth, complete chest recoil, few interruptions to compressions, and appropriate ventilation.
The guidelines offer several changes to advanced cardiac life support (ACLS). The algorithm was simplified by removing vasopressin, because the authors note that “the combined use of vasopressin and epinephrine offers no advantage to using standard-dose epinephrine in cardiac arrest.”
Likewise, the guidelines note conflicting studies to support the use of lidocaine after return of spontaneous circulation (ROSC). “However, the initiation or continuation of lidocaine may be considered immediately after ROSC from VF/pulseless ventricular tachycardia cardiac arrest,” the guideline authors wrote.
Finally, the guidelines highlight updates in post–cardiac arrest care, including a wider range of target temperatures, between 32°C and 36°C, to be maintained for at least 24 hours in comatose adults with ROSC after cardiac arrest. In comparison, the 2010 guidelines called for a target temperature range of 32°C to 34°C for 12 to 24 hours.
The guidelines also detail new updates for acute coronary syndrome, pediatric BLS, pediatric ACLS, and neonatal resuscitation.
Complex Picture Emerges of Prescription Opioid Abuse