Introduction

The publication of the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care marks the 50th anniversary of modern CPR. In 1960 Kouwenhoven, Knickerbocker, and Jude documented 14 patients who survived cardiac arrest with the application of closed chest cardiac massage.1 That same year, at the meeting of the Maryland Medical Society in Ocean City, MD, the combination of chest compressions and rescue breathing was introduced.2 Two years later, in 1962, direct-current, monophasic waveform defibrillation was described.3 In 1966 the American Heart Association (AHA) developed the first cardiopulmonary resuscitation (CPR) guidelines, which have been followed by periodic updates.4 During the past 50 years the fundamentals of early recognition and activation, early CPR, early defibrillation, and early access to emergency medical care have saved hundreds of thousands of lives around the world. These lives demonstrate the importance of resuscitation research and clinical translation and are cause to celebrate this 50th anniversary of CPR.

Challenges remain if we are to fulfill the potential offered by the pioneer resuscitation scientists. We know that there is a striking disparity in survival outcomes from cardiac arrest across systems of care, with some systems reporting 5-fold higher survival rates than others.5–9 Although technology, such as that incorporated in automated external defibrillators (AEDs), has contributed to increased survival from cardiac arrest, no initial intervention can be delivered to the victim of cardiac arrest unless bystanders are ready, willing, and able to act. Moreover, to be successful, the actions of bystanders and other care providers must occur within a system that coordinates and integrates each facet of care into a comprehensive whole, focusing on survival to discharge from the hospital. This executive summary highlights the major changes and most provocative recommendations in the 2010 AHA Guidelines for CPR and Emergency Cardiovascular Care (ECC).

The scientists and healthcare providers participating in a comprehensive evidence evaluation process analyzed the sequence and priorities of the steps of CPR in light of current scientific advances to identify factors with the greatest potential impact on survival. On the basis of the strength of the available evidence, they developed recommendations to support the interventions that showed the most promise. There was unanimous support for continued emphasis on high-quality CPR, with compressions of adequate rate and depth, allowing complete chest recoil, minimizing interruptions in chest compressions and avoiding excessive ventilation. High-quality CPR is the cornerstone of a system of care that can optimize outcomes beyond return of spontaneous circulation (ROSC). Return to a prior quality of life and functional state of health is the ultimate goal of a resuscitation system of care.

The 2010 AHA Guidelines for CPR and ECC are based on the most current and comprehensive review of resuscitation literature ever published, the 2010 ILCOR International Consensus on CPR and ECC Science With Treatment Recommendations.10 The 2010 evidence evaluation process included 356 resuscitation experts from 29 countries who reviewed, analyzed, evaluated, debated, and discussed research and hypotheses through in-person meetings, teleconferences, and online sessions (“webinars”) during the 36-month period before the 2010 Consensus Conference. The experts produced 411 scientific evidence reviews on 277 topics in resuscitation and emergency cardiovascular care. The process included structured evidence evaluation, analysis, and cataloging of the literature. It also included rigorous disclosure and management of potential conflicts of interest, which are detailed in Part 2: “Evidence Evaluation and Management of Potential and Perceived Conflicts of Interest.”

The recommendations in the 2010 Guidelines confirm the safety and effectiveness of many approaches, acknowledge ineffectiveness of others, and introduce new treatments based on intensive evidence evaluation and consensus of experts. These new recommendations do not imply that care using past guidelines is either unsafe or ineffective. In addition, it is important to note that they will not apply to all rescuers and all victims in all situations. The leader of a resuscitation attempt may need to adapt application of these recommendations to unique circumstances.

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Introduction

Evidence-based medicine integrates the best available evidence and clinical expertise to deliver the finest possible patient care.¹ The victim of cardiac arrest requires immediate action, and potential rescuers must be ready to respond. Evidence must be compiled, analyzed, and discussed; clear recommendations must be established prior to the patient encounter. The 2010 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) (2010 AHA Guidelines for CPR and ECC) are based on a transparent, expert review of scientific evidence, informed by the clinical expertise of the writing teams. These guidelines are designed to provide rescuers and clinicians with a strategy for action that can save lives from cardiac arrest. Clinicians should always apply these evidence-based guidelines in combination with clinical judgment.

The International Liaison Committee on Resuscitation (ILCOR), an international consortium of many of the world’s resuscitation councils, was formed in 1992, in part to collect, discuss, and debate scientific data on resuscitation. The majority of ILCOR’s work focuses on reviewing published, peer-reviewed evidence on resuscitation to produce science-based consensus summaries.² As one of ILCOR’s member councils, the AHA transforms international scientific consensus statements into periodic revisions of the AHA Guidelines for CPR and ECC.

During production of the 1992 AHA Guidelines for CPR and ECC, an evidence evaluation process was developed to guide topic experts in conducting a thorough evidence review, distilling the evidence, and producing treatment recommendations. This evidence evaluation process was revised in 2000, when an international set of CPR and ECC guidelines was developed. The evidence evaluation process was refined for the creation of the 2005 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (ILCOR 2005 CPR Consensus).³ For the 2010 AHA Guidelines for CPR and ECC, the process was further refined, and a comprehensive description of the 2010 process has been published.⁴ The purpose of this chapter is to briefly describe this evidence evaluation process and its translation to the 2010 AHA Guidelines for CPR and ECC.

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Introduction

The goals of resuscitation are to preserve life, restore health, relieve suffering, limit disability, and respect the individual’s decisions, rights, and privacy. Decisions about cardiopulmonary resuscitation (CPR) efforts are often made in seconds by rescuers who may not know the victim of cardiac arrest or whether an advance directive exists. As a result, administration of CPR may be contrary to the individual’s desires or best interests.^1–3 However, practice is evolving as more emergency physicians reportedly honor legal advance directives in decisions about resuscitation.^4–7 This section provides guidelines for healthcare providers who are faced with the difficult decision to provide or withhold emergency cardiovascular care.

Ethical Principles

Healthcare professionals should consider ethical, legal, and cultural factors^8,9 when caring for those in need of CPR. Although healthcare providers must play a role in resuscitation decision making, they should be guided by science, the individual patient or surrogate preferences, local policy, and legal requirements.

Principle of Respect for Autonomy¹⁰
The principle of respect for autonomy is an important social value in medical ethics and law. The principle is based on society’s respect for a competent individual’s ability to make decisions about his or her own healthcare. Adults are presumed to have decision-making capability unless they are incapacitated or declared incompetent by a court of law. Truly informed decisions require that individuals receive and understand accurate information about their condition and prognosis, as well as the nature, risks, benefits, and alternatives of any proposed interventions. The individual must deliberate and choose among alternatives by linking the decision to his or her framework of values. Truly informed decisions require a strong healthcare provider–patient relationship/communication and a 3-step process: (1) the patient receives and understands accurate information about his or her condition, prognosis, the nature of any proposed interventions, alternatives, and risks and benefits; (2) the patient is asked to paraphrase the information to give the provider the opportunity to assess his or her understanding and to correct any misimpressions; and (3) the patient deliberates and chooses among alternatives and justifies his or her decision.¹¹

When decision-making capacity is temporarily impaired by factors such as active illness, treatment of these conditions may restore capacity. When the individual’s preferences are unknown or uncertain, emergency conditions should be treated until further information is available.

Advance Directives, Living Wills, and Patient Self-Determination
A recent study documented that more than a quarter of elderly patients require surrogate decision making at the end of life. Advance directives, living wills, and executing a durable power of attorney for health care ensure that when the patient is unable to make decisions, the preferences that the individual established in advance can guide care. These decisions are associated with less aggressive medical care near death, earlier hospice referrals for palliation, better quality of life, and caregiver’s bereavement adjustment.¹²

A healthcare advance directive is a legal binding document that in the United States (US) is based on the Patient Self-Determination Act of 1990.¹³ It communicates the thoughts, wishes, or preferences for healthcare decisions that might need to be made during periods of incapacity. The Patient Self-Determination Act mandated that healthcare institutions should facilitate the completion of advance directives if patients desire them.¹³ Advance directives can be verbal or written and may be based on conversations, written directives, living wills, or durable power of attorney for health care. The legal validity of various forms of advance directives varies from jurisdiction to jurisdiction. Courts consider written advance directives to be more trustworthy than recollections of conversations.

A living will may be referred to as a “medical directive” or “declaration” or “directive to physicians,” and it provides written direction to healthcare providers about the care that the individual approves should he or she become terminally ill and be unable to make decisions. A living will constitutes evidence of the individual’s wishes, and in most areas it can be legally enforced.

A durable power of attorney for health care is a legal document that appoints an authorized person to make healthcare decisions (not limited to end-of-life decisions). Simply put, a living will affects the care received, and a durable power of attorney accounts for unforeseen circumstances. The latter decisions may be in conflict with the living will or advance directive; at the time of the unforeseen circumstances they are considered to be valid expressions of the patient’s best interests.¹⁴

A comprehensive healthcare advance directive combines the living will and the durable power of attorney for health care into one legally binding document.

As a patient’s medical condition and desire for types of medical treatment may change over time, all types of advance directives should be revisited regularly. Most importantly the presence of an advance directive, a living will, or a durable power of attorney for health care is closely associated with ensuring that personal preferences match the actual care received, as documented in a survey of surrogates for patients of at least 60 years of age who died between 2000 and 2006 and required surrogate decision making at some point in their care.¹⁴

A Do Not Attempt Resuscitation (DNAR) order is given by a licensed physician or alternative authority as per local regulation, and it must be signed and dated to be valid.^15,16 In many settings, “Allow Natural Death” (AND) is becoming a preferred term to replace DNAR, to emphasize that the order is to allow natural consequences of a disease or injury, and to emphasize ongoing end-of-life care.¹⁷ The DNAR order should explicitly describe the resuscitation interventions to be performed in the event of a life-threatening emergency. In most cases, a DNAR order is preceded by a documented discussion with the patient, family, or surrogate decision maker addressing the patient’s wishes about resuscitation interventions. In addition, some jurisdictions may require confirmation by a witness or a second treating physician.

Surrogate Decision Makers
In the event of incapacity, an adult may require a surrogate decision maker to make medical decisions. In the event that the individual has a durable power of attorney for health care, the person appointed by that document is authorized to make medical decisions within the scope of authority granted by the document. If the individual has a court-appointed guardian with authority to make healthcare decisions, the guardian becomes the authorized surrogate.

If there is no court-appointed or other authority, a close relative or friend can become a surrogate decision maker. Most jurisdictions have laws that designate the legally authorized surrogate decision maker for an incompetent patient who has not identified a decision maker through a durable power of attorney for health care. Surrogate decision makers should base their decisions on the individual’s previously expressed preferences, if known; otherwise, surrogates should make decisions based on their understanding of what constitutes the best interests of the individual.

Pediatric Decision Making
As a general rule, minors are considered incompetent to provide legally binding consent about their health care. Parents or guardians are generally empowered to make healthcare decisions on their behalf, and in most situations, parents are given wide latitude in terms of the decisions they make on behalf of their children. Parental authority is not absolute, however, and when a parent or guardian’s decision appears to place the child at significant risk of serious harm as compared to other options, medical providers may seek to involve state agencies (eg, child protective services or a court determination) to allow treatment of the child over parental objections.¹⁸

A child should be involved in decision making at a level appropriate for the child’s maturity. Children should be asked to consent to healthcare decisions when able within the legal definition of a consenting adult based on local policy and legislation. Children <14 years of age (in Canada) and <18 years of age (in the US) rarely possess the legal authority to consent to their health care except under specific legally defined situations (emancipated minors, mature minors, and for specific health conditions such as sexually transmitted diseases and pregnancy-related care). In situations where an older child will not consent, the dissent should be carefully considered by the treating provider.

Principle of Futility
Patients or families may ask for care that is highly unlikely to improve health outcomes. Healthcare providers, however, are not obliged to provide such care when there is scientific and social consensus that the treatment is ineffective. If the purpose of a medical treatment cannot be achieved, the treatment can be considered futile.

An objective criterion for medical futility was defined in 1990 for interventions and drug therapy as imparting a <1% chance of survival.¹⁹ Although this criterion may be controversial, it remains a basis for current futility research. An obvious example of an inappropriate or futile intervention is providing CPR for a patient who has suffered irreversible death. Without objective signs of irreversible death (eg, decapitation, rigor mortis, or decomposition) and in the absence of known advance directives declining resuscitative attempts, full resuscitation should be offered.

Conditions such as irreversible brain damage or brain death cannot be reliably assessed or predicted at the time of cardiac arrest. Withholding resuscitation and the discontinuation of life-sustaining treatment during or after resuscitation are ethically equivalent. In situations where the prognosis is uncertain, a trial of treatment may be initiated while further information is gathered to help determine the likelihood of survival, the patient’s preferences, and the expected clinical course (Class IIb, LOE C).

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Introduction

Cardiopulmonary resuscitation (CPR) is a series of lifesaving actions that improve the chance of survival following cardiac arrest.¹ Although the optimal approach to CPR may vary, depending on the rescuer, the victim, and the available resources, the fundamental challenge remains: how to achieve early and effective CPR. Given this challenge, recognition of arrest and prompt action by the rescuer continue to be priorities for the 2010 AHA Guidelines for CPR and ECC. This chapter provides an overview of cardiac arrest epidemiology, the principles behind each link in the Chain of Survival, an overview of the core components of CPR (see Table 1), and the approaches of the 2010 AHA Guidelines for CPR and ECC to improving the quality of CPR. The goal of this chapter is to integrate resuscitation science with real-world practice in order to improve the outcomes of CPR.

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Introduction

Basic life support (BLS) is the foundation for saving lives following cardiac arrest. Fundamental aspects of BLS include immediate recognition of sudden cardiac arrest (SCA) and activation of the emergency response system, early cardiopulmonary resuscitation (CPR), and rapid defibrillation with an automated external defibrillator (AED). Initial recognition and response to heart attack and stroke are also considered part of BLS. This section presents the 2010 adult BLS guidelines for lay rescuers and healthcare providers. Key changes and continued points of emphasis from the 2005 BLS Guidelines include the following:

• Immediate recognition of SCA based on assessing unresponsiveness and absence of normal breathing (ie, the victim is not breathing or only gasping)
• “Look, Listen, and Feel” removed from the BLS algorithm
• Encouraging Hands-Only (chest compression only) CPR (ie, continuous chest compression over the middle of the chest) for the untrained lay-rescuer
• Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
• Health care providers continue effective chest compressions/CPR until return of spontaneous circulation (ROSC) or termination of resuscitative efforts
• Increased focus on methods to ensure that high-quality CPR (compressions of adequate rate and depth, allowing full chest recoil between compressions, minimizing interruptions in chest compressions and avoiding excessive ventilation) is performed
• Continued de-emphasis on pulse check for health care providers
• A simplified adult BLS algorithm is introduced with the revised traditional algorithm
• Recommendation of a simultaneous, choreographed approach for chest compressions, airway management, rescue breathing, rhythm detection, and shocks (if appropriate) by an integrated team of highly-trained rescuers in appropriate settings

Despite important advances in prevention, SCA continues to be a leading cause of death in many parts of the world.¹ SCA has many etiologies (ie, cardiac or noncardiac causes), circumstances (eg, witnessed or unwitnessed), and settings (eg, out-of-hospital or in-hospital). This heterogeneity suggests that a single approach to resuscitation is not practical, but a core set of actions provides a universal strategy for achieving successful resuscitation. These actions are termed the links in the “Chain of Survival.” For adults they include

• Immediate recognition of cardiac arrest and activation of the emergency response system
• Early CPR that emphasizes chest compressions
• Rapid defibrillation if indicated
• Effective advanced life support
• Integrated post–cardiac arrest care

When these links are implemented in an effective way, survival rates can approach 50% following witnessed out-of-hospital ventricular fibrillation (VF) arrest.² Unfortunately survival rates in many out-of-hospital and in-hospital settings fall far short of this figure. For example, survival rates following cardiac arrest due to VF vary from approximately 5% to 50% in both out-of-hospital and in-hospital settings.^3,4 This variation in outcome underscores the opportunity for improvement in many settings.

Recognition of cardiac arrest is not always straightforward, especially for laypersons. Any confusion on the part of a rescuer can result in a delay or failure to activate the emergency response system or to start CPR. Precious time is lost if bystanders are too confused to act. Therefore, these adult BLS Guidelines focus on recognition of cardiac arrest with an appropriate set of rescuer actions. Once the lay bystander recognizes that the victim is unresponsive, that bystander must immediately activate (or send someone to activate) the emergency response system. Once the healthcare provider recognizes that the victim is unresponsive with no breathing or no normal breathing (ie, only gasping) the healthcare provider will activate the emergency response system. After activation, rescuers should immediately begin CPR.

Early CPR can improve the likelihood of survival, and yet CPR is often not provided until the arrival of professional emergency responders.⁵ Chest compressions are an especially critical component of CPR because perfusion during CPR depends on these compressions. Therefore, chest compressions should be the highest priority and the initial action when starting CPR in the adult victim of sudden cardiac arrest. The phrase “push hard and push fast” emphasizes some of these critical components of chest compression. High-quality CPR is important not only at the onset but throughout the course of resuscitation. Defibrillation and advanced care should be interfaced in a way that minimizes any interruption in CPR.⁶

Rapid defibrillation is a powerful predictor of successful resuscitation following VF SCA.^7,8 Efforts to reduce the interval from collapse to defibrillation can potentially improve survival in both out-of-hospital and in-hospital settings.^8,9 Depending on the setting and circumstances, earlier defibrillation may be achieved by a variety of strategies that include rescuers who are laypersons, nontraditional first responders, police, emergency medical services (EMS) professionals, and hospital professionals.^9–12 One of these strategies is the use of an AED. The AED correctly assesses heart rhythm, enabling a rescuer who is not trained in heart rhythm interpretation to accurately provide a potentially lifesaving shock to a victim of SCA.¹³

Immediate recognition and activation, early CPR, and rapid defibrillation (when appropriate) are the first three BLS links in the adult Chain of Survival. BLS care in the out-of-hospital setting is often provided by laypersons who may be involved in a resuscitation attempt only once in their lives. Thus, creating an effective strategy to translate BLS skills to real-world circumstances presents a challenge. This section updates the adult BLS guidelines with the goal of incorporating new scientific information while acknowledging the challenges of real-world application. Everyone, regardless of training or experience, can potentially be a lifesaving rescuer.

The rest of this chapter is organized in sections that address the emergency response system, adult BLS sequence, adult BLS skills, use of an AED, special resuscitation situations, and the quality of BLS. The “Adult BLS Sequence” section provides an overview and an abridged version of the BLS sequence. The “Adult BLS Skills” section provides greater detail regarding individual CPR skills and more information about Hands-Only (compression-only) CPR. The “Special Resuscitation Situations” section addresses acute coronary syndromes, stroke, hypothermia, and foreign body airway obstruction. Because of increasing interest in monitoring and ensuring the quality of CPR, the last section focuses on the quality of BLS.

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