Australian Resuscitation Guidelines: Applying the evidence and simplifying the process

See also pp. 322–4; 325–7; 328–9; 330–1; 332–4; 335–6, 337–56; 357–71 Formal procedures for cardiopulmonary resuscitation (CPR) were first developed in the 1960s. Drug management and some approaches have been refined following pharmacological and technological advancements, although the fundamental principles and practices essentially remained unchanged. The International Liaison Committee on Resuscitation (ILCOR) was formed in 1992. It comprised representatives from the American Heart Association, Australian Resuscitation Council (ARC), European Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, New Zealand Resuscitation Council and the Resuscitation Council of Southern Africa. Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care were developed under the aegis of ILCOR in 2000.1, 2 After the publication of these guidelines, ILCOR was determined that the next set of recommendations should be evidence-based and developed from systematic reviews of the clinical literature. The Consensus of Science and Treatment Recommendations or CoSTR came into being to achieve this, as a process to guide methodology from question formation, through systematic literature review to recommendations.3, 4 Approximately 430 questions were developed seeking the evidence for each procedural or interventional manoeuvre in Basic Life Support, Advanced Life Support, Paediatric Life Support and Neonatal Life Support (the latter largely focused on the resuscitation of the newborn). In addition, an interdisciplinary group developed and reviewed a number of questions focused on the ethics of resuscitation, clinical education, logistical and other professional issues. Subsequently, a review of first aid procedure recommendations was conducted along similar lines. Three hundred and eighty international experts in all were involved in the review processes. Each question was researched and reviewed in keeping with CoSTR procedures by at least two reviewers, one from the American Heart Association and one from other ILCOR member organizations. A structured worksheet was completed independently by each reviewer for every question. Fifteen Australian and New Zealand experts were among those involved, who completed 44 literature reviews and worksheets. Reviewers provided CoSTR statements and treatment recommendations for each question, which were presented and debated at subsequent ILCOR meetings, and developed into the final document by the various writing teams. The member bodies reviewed and further refined the statements and recommendations prior to their final adoption by ILCOR. Each ILCOR member body has developed its own guidelines for local use, based on its interpretations of the statements and recommendations published by ILCOR in November from the CoSTR documents.5, 6 The processes are well described in the ARC's introductory guidelines and statements.7 The Australian guidelines were distributed to ARC subscribers and posted on the ARC website in early March 2006. It is essential that the medical community at large has access to contemporary clinical care recommendations that can be identified by, and accessed from, standard searches of the clinical literature. Emergency Medicine Australasia is one of the Australian journals that will be publishing new and revised ARC guidelines as they become available. The principal ARC Guideline Development, Basic Life Support, Advanced Life Support and Paediatric Advanced Life Support Guidelines have therefore been reproduced in this journal. The new guidelines have simplified resuscitation procedures. The so-called ‘Chain of Survival’ comprising Early Access, Early CPR, Early Defibrillation and Early ACLS is the guiding concept behind the development of response/responder systems.8 It has been retained as the key for responder system logic, construction and development, and has been endorsed as fundamental to the approach to CPR. Thus, it is recommended that help is summoned at the start of resuscitation in sudden adult cardiac arrest, on the premise that the underlying cause in adults is cardiogenic and that timely access to defibrillation is the definitive intervention. Conversely, it is recommended that resuscitation be commenced first and help summoned expediently in circumstances such as in drowning, trauma and in paediatric cardiac arrest. The Dangers Response Airway Breathing Circulation or DR ABC approach to resuscitation has changed to DR ABCD. C now stands for compressions and D stands for defibrillation.9 Unconscious victims are no longer turned onto the side prior to clearing the airway, but are examined on their back or in the position found. A patient is only rolled on the side to facilitate the removal of a definite foreign body.10 After determining apnoea, two breaths are delivered.11 In the absence of ‘signs of life’, the hands are placed in the middle of the chest without measuring for the compression point and external cardiac compressions are commenced.12 The ratio of compressions to ventilation is 30:2 in continuous cycles at a compression rate of 100/min, with no pause to determine the presence or absence of circulation. This ratio is now universal with the exception of resuscitation of the newborn and intubated victims.9, 13 A high level of operator error and indecision has been observed when assessing the pulse at the initiation of resuscitation and similar indecision is likely with pulse checks to determine return of spontaneous circulation.14-16 Accordingly, ‘recovery checks’ are no longer recommended in Basic Life Support.9 CPR should not be interrupted except for an intervention that may directly lead to return of spontaneous circulation, such as determining cardiac rhythm and administration of a DC shock. CPR may also be interrupted when signs of return of spontaneous circulation are present, but if they disappear, CPR must be recommenced.17 Expired Air Resuscitation (EAR) has been renamed ‘rescue breathing’.11 Rescue breathing is no longer a stand-alone technique, but is integral to CPR. Repeated cycles of two ventilations and 30 compressions are continued in all victims requiring resuscitation, as a pulse check is not used to identify the need for chest compressions. Basic Life Support approaches to the management of choking have been simplified. The ARC does not recommend the Heimlich Manoeuvre and has withdrawn the lateral chest thrust. CPR is the treatment for unconscious victims with complete airway obstruction. Conscious patients with an effective cough should be encouraged to cough while being closely observed. Back blows and chest thrusts are recommended for conscious adults with an ineffective cough. Young children and babies can be positioned head down prior to delivering back blows.10, 13 Compressions continue uninterrupted at a rate of approximately 100/min with concurrent ventilation at a rate of 8–10/min, when resuscitating an adult using an advanced airway such as an endotracheal tube or laryngeal mask airway. A starting ratio of one ventilation to 15 compressions is suggested.18 A ventilation compression ratio of two ventilations to 15 compressions is recommended in children,19 and the ratio remains unchanged at one ventilation to three compressions in the newborn.20 Defibrillation of ventricular fibrillation and ventricular tachycardia is still recognized as the single most efficacious procedure in survival from sudden cardiac arrest.18, 21-24 The focus on out-of-hospital CPR has been on early access to defibrillation strategies in the community, in view of the development and spread of the lunch-box-sized, user-friendly automated external defibrillator (AED) with smart technology. The use of these devices by lay persons was introduced into the Australian first aid curriculum for lay first aiders in 1993. At the Spark of Life meeting in Melbourne in 1996 assertions that defibrillation should be considered part of Basic Life Support and that defibrillation was within the capability of the lay first aider were rejected. However, owing to improved, simpler technology and confidence in AED use, with evidence-based outcomes supporting rapid response defibrillation and the success of ‘first responder systems’, defibrillation is now accepted as a Basic Life Support intervention: ‘Attach an AED as soon as available and follow its prompts’.9 Since the introduction of automated external defibrillation, emergency medical systems have endeavoured to achieve earlier access to defibrillation by development and refinement of practices in prehospital emergency care. Similarly, response dynamics have also been developed for responding to cardiac arrest in-hospital. The increasing availability of AED devices in public and private places has safely placed defibrillation in the hands of non-traditional responders, who compliment the ambulance and emergency responder systems. The original Australasian College for Emergency Medicine (ACEM) Statement on Early Access to Defibrillation supported early defibrillation by then non-traditional responders,25 which is implied in the recently updated statement.26 ACEM recommends that all clinical staff within health-care settings should have rapid access to an AED or a defibrillator with AED capability, in a new policy statement entitled ‘Early Access to Defibrillation within Health Care Settings’. An AED, oxygen, suction, and basic oxygen and ventilation devices are considered as essential equipment items for an emergency response in ambulatory or non-acute health-care settings.27 The delivery of three stacked DC shocks is now restricted to the first electrical therapy intervention by trained health-care professionals using manual defibrillators for witnessed cardiac arrest in advanced life support for adults and children. After this, and in all other situations, a single DC shock is recommended immediately followed by 2 min of CPR. In Advanced Life Support, CPR should be briefly interrupted to assess the need for further defibrillation, to determine return of spontaneous circulation and the need for other interventions to restore spontaneous circulation.18 There is uncertainty about the nature and construct of defibrillation education programmes. Children as young as 9 years of age can be taught to competently use a defibrillator in a CPR skills laboratory.28 Programme lengths vary from no prior instruction to 2 day courses. Four-hour face-to-face programmes are common. The need for prior training in CPR is a point of debate and course content remains uncertain. No evidence-based study has looked at a ‘total context’ needs analysis of training. All current programmes appear effective, with little difference in outcome between 2 and 4 h courses. However, first responder programmes appear to have the best outcomes.29 AED skill retention is generally high at 1, 3 and 6 months. Retraining, if necessary, may be brief. Actual AED use in a cardiac arrest situation seems to cement operator proficiency,29, 30 but the ongoing psychological impact on the lay community from using AEDs is unknown. All modes of CPR training contribute to learning development. However, it is recommended that CPR proficiency is assessed on a resuscitation mannequin by an appropriately qualified trainer.31, 32 Drug therapy in resuscitation remains essentially unchanged. Recommendations remain largely centred on expert opinion, based on limited clinical trials and applied pharmacological actions of the therapeutic substances. Induced mild therapeutic hypothermia is recommended for victims who remain unconscious following return of spontaneous circulation in out-of-hospital sudden cardiac arrest, which will potentially pose significant logistical and organizational challenges to all ED and intensive care units.18, 33, 34 Close glucose monitoring and maintenance of a normal blood glucose range is also recommended.18 When to cease advanced life support remains unclear, determined by pre-arrest status, response to resuscitation, remedial factors, likely outcome and opinions of experienced personnel. It is recommended in children that after 20–30 min of effective advanced paediatric life support resuscitation should cease in the absence of a treatable cause, or in recurring or refractory ventricular fibrillation. Return of spontaneous circulation during any of the resuscitative effort resets the clock.19, 35 There are no recommendations to guide cessation of advanced life support in adults. The use of Medical Emergency Teams (MET) is recommended. These teams should be summoned to the physiologically compromised, with the aim of preventing progression to full cardiac arrest by early intervention. Additionally, MET teams also play an important role in determining ongoing care plans and treatment options being perused.34 The ‘keep it simple approach’ should prevail for out of hospital cardiac arrest and in terms of external cardiac compression, one should ‘push hard, push fast, allow complete release and minimize interruptions’. Aetiology-specific responses will improve survival with in-hospital cardiac arrest. The quality of CPR should be emphasized, adjuncts used and effects monitored, as many advanced techniques require further evaluation. MET teams should be used to assist with critical care management and decision making including when not to resuscitate. The final message is to look for ventricular fibrillation, special treatable circumstances and to not over ventilate. I wish to acknowledge the ARC Executive, Members of the ARC, Chairs and Members of the ARC State Branches for all our collective endeavours over the whole of the CoSTR process. I offer my thanks to the Australians and New Zealanders who spent hundreds of hours undertaking systematic literature reviews, developing worksheets and revising them on a number of occasions as part of the international review; also to the Department of Emergency Medicine at Peninsula Health for assistance with preparation of the manuscript. None declared.

Fetched live from OpenAlex and de-inverted. Abstracts are not stored in this database: the inverted indexes are 8.6 GB of the frame’s 9.3 GB of text, and the host has 13 GB free.