This report is based on final published ACLS changes reported in 
Circulation Supplement for August 22, 2000. All readers are 
encouraged to read the findings for themselves-this review is not 
meant to be comprehensive nor should it substitute for an ACLS 
provider's own inquiry into these subjects, issues and 
recommendations. This material in Circulation represents a process 
of intensive review and consensus begun well over 18 months ago. 
A "roll out" is scheduled for September 21-24 in San Diego where 
this information will be further explained and how it will be 
incorporated in future ACLS will be presented. This, then represents 
the content that the San Diego conference will be based upon..

Ethical Aspects of CPR and ECC (Emergency Cardiovascular Care)

"CPR and ECC have the same goals as other medical interventions: to preserve life, restore health, relieve suffering, and limit disability."

Patient autonomy emphasized.

Advance Directives-cannot be used to withhold life-saving treatment unless:

• A surrogate has given authorization;
• Patient has a terminal condition certified by two physicians, or
• Patient is in a persistent vegetative state certified by two physicians (one of whom has expertise in assessing brain function)

Living wills constitute clear wishes and should be enforceable, in most circumstances.

Realize that patients change their mind frequently-sometimes within months of an initial decision--one study found that those who opted for DNAR status were more likely to change that status than those who did not opt for it.

Criteria for not starting CPR-

• Valid DNAR order
• Signs of irreversible death
• No physiological benefit can be expected (maximum therapy for "progressive septic or cardiogenic shock" has been reached and vital functions continue to deteriorate)

Withhold delivery resuscitation if

• Confirmed gestation less than 23 weeks; or
• Birthweight less than 400 grams;
• Anencephaly;
• Confirmed trisomy 13 or 18.

Recommendation: CPR can be discontinued if no return of spontaneous pulse during BLS and ACLS (and no mitigating circumstances such as hypothermia, age, toxins, overdose)

• After 30 minutes of interventions for adults;
• 15 minutes for newborns.

For BLS providers, continue unless---

• pulse/breathing return;
• care assumed by higher level of provider;
• reliable signs of irreversible death;
• rescuer exhaustion, compelling environmental hazards or unreasonable life/death risk to others
• presentation of valid DNAR order

Inhospital DNAR orders are generally not transferable to out-of-hospital situations. Family presence during resuscitation attempts in-hospital is premised on social worker or nurse stationed with family (explain, comfort, clarify) and having sophisticated rehearsal/role plays prior to working real situations.

Other ethical issues mentioned: withdrawal of life support, notifying survivors, organ and tissue donation, research/training on the newly dead…

Adult BLS (Basic Life Support)

Rescue Breathing

• Without supplementaloxygen - target 10ml/kg (approx. 700-1000ml) for 2 seconds (class IIa);
• With at least supplemental oxygen of at least 40% concentration-ventilate with tidal volumes reduced to 6-7 ml/kg (approx. 400-600ml) for 1-2 seconds (class IIb)

CPR

• Lay rescuers are not expected to do pulse checks (instead check for signs of circulation---coughing, breathing, or movement), though healthcare providers will continue to check for pulses;
• Lay rescuers will not be taught former procedure for unconscious patient with foreign body airway obstruction, instead they will perform CPR adding only an airway visualization step at ventilation steps;
• "untrained rescuers" should phone first in cases of a responsive victim with a foreign body airway obstruction;

Regarding Compressions

• Compression rate should be 100 per minute rather than the previous recommendation of 80-100 (class IIb);
• Compression-ventilation ratio is 15:2 for both 1 and 2-rescuer CPR if patient is not intubated (Class IIb);
• Chest compression-no ventilation CPR okay for dispatcher-coached CPR and those that are unable/unwilling to ventilate (class IIa);
• Audio prompts/metronomic coaching devices improve CPR (class IIb);

The BLS Response

• For most victims of sudden nontraumatic cardiac arrest, "the time from collapse to defibrillation is the greatest determinant to survival."
• Some studies are now suggesting up to 15% of peds/adolescent cardiac arrest victims are in VT/VF;
• New exceptions to the 'phone first' rule for adults (over 8 years of age):
  • Submersion / near drowning
  • Trauma arrest
  • Drug overdose
• New exceptions to the 'phone fast' rule for children (under 8 years of age) will be cardiac arrest in cases with history of high risk of arrhythmias

Stroke Management

• The 7 D's
  • Out of hospital-Detect; Dispatch; Delivery (transport)
  • In hospital-Door (rapid triage upon arrival); Data (CT scan and diagnose type of stroke);
  • Decision (identify fibrolytic therapy candidates); Drug (treat with fibrolytic).
• Only half of stroke victims in US currently use EMS transport.
• 85% of strokes occur at home.

Procedures

• Recovery position (Class Indeterminate). If patient is in position for more than 30 minutes, turn patient to opposite side (for blood distribution, especially to dependent arm)
• Rescue breathing
  • Mouth-to-mouth-10-12 per minute ("one breath every 4-5 seconds");
  • Initial breaths-2 in US, 5 in Europe, Australia, and New Zealand;
  • Take a deep breath before each ventilation to maximize the oxygen content;
  • "Some evidence in animal models and limited adult clinical trials suggests that positive-pressure ventilation is not essential during the initial 6 to 12 minutes of adult CPR."
• Cricoid pressure
  • Apply "moderate rather than excessive" pressure in performing this.
• Pulse checks eliminated for lay public because of lengthy delays while checking and unreliable results of pulse checks
• Compressions
  • 15 consecutive compression preferred over 5 because more compressions actually occur per minute and greater intravascular pressures are generated with 15 compressions in a row-both lay public and healthcare providers should do this for two-person CPR in the non-intubated patient; alternative description for hand placement instruction to lay public-"…place heel of one hand in the center of the chest between the nipples."
  • Depress chest 1.5-2 inches, more in "large" patients…
  • Netherlands performs sequence "CAB" with compressions before airway and breathing; no data to show of CAB or ABC superior.

Disease Transmission

• 15 reports of CPR-related infection noted in the literature between 1960 and 1998. There were no reports of such infection in scientific journals between 1998 and 2000. Disease transmissions reported include Helicobacter pylori, Mycobacterium tuberculosis, meningococcus, herpes simplex, shigella, streptococcus, salmonella and neisseria gonorrhoeae.
• No reports of HIV, HBV, Hepatitis C, or cytomegalovirus.
• Face masks are more effective barriers than face shields. Despite the presence of one-way valves in face shields, one study cited bacterial contamination from the patient side to the rescuer side of the shield 6 out of 8 times

Reviews still to come: post resuscitation management, special situations, and pediatric guidelines