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Heart SmarterEMS Implications of the

2005 AHA Guidelinesfor ECC & CPR

An exclusive supplement to JEMS (Journal of Emergency Medical Services)sponsored by The American Heart Association, Laerdal Medical Corp., Medtronic, Philips Medical Systems & ZOLL Medical Corp.

Heart SmarterEMS Implications of the 2005 AHA Guidelines for ECC & CPR

For older children, the emphasis is on achieving adequate compressiondepth with minimal interruptions, using one or two hands according to rescuer preference.

On the cover: Seattle F.D. paramedics and firefighters deliver uninterrupted compressionswhile ventilating, administering medication andinterpreting the cardiac rhythm.PHOTO JONNY LAYEFSKY

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4 Contributors

6 From the EditorBy A.J. Heightman, MPA, EMT-P

By Jerry Potts, PhD, Tom P. Aufderheide, MD, FACEP,Todd J. Crocco, MD, John Field, MD,Louis Gonzales, EMT-P, Mary Fran Hazinski, RN, MSN, Edward C. Jauch, MD, & Arno Zaritsky, MD

6 What’s New & Why8 Summary of

Major Changes12 Revising Your

Protocols

29 Lay Rescuer AED Programs & the2005 Guidelines forECC & CPRPlus ... Frequently Asked Questionsfor Program DirectorsBy Mary Newman

21

Vice President/Publisher Jeff BerendAdvertising Director Judi LeidigerDirector of Print & Electronic Publishing Tim FrancisEditor-in-Chief A.J. HeightmanSupplement Editor Keri LosavioArt Director Joe Camacho

Heart Smarter is an editorial supplement sponsored by The American HeartAssociation, Laerdal Medical Corp., Medtronic, Philips Medical Systems & ZOLLMedical Corp. and published by Elsevier/Jems Communications, 525 B Street, Ste. 1900, San Diego, CA 92101-4495; 800/266-5367 (Fed. ID #13-935377).Copyright 2006 Elsevier Inc. No material may be reproduced or uploaded on computer network services without the expressed permission of the publisher.Subscription information: To subscribe to a Jems/Elsevier publication, visitwww.jems.com. Advertising information: Rates are available on request. Contact Jems Communications, Advertising Department, 525 B Street, Ste. 1900,San Diego, CA 92101-4495; 800/266-5367.

the GUIDELINES

JEMS | HEART SMARTER 3

4 JEMS | HEART SMARTER

ContributorsJerry Potts, PhD, is the director of sciencefor the American Heart Association’sEmergency Cardiovascular Care Programs.

Dr. Potts holds a doctor-ate in cellular andmolecular physiology.For the past nine years,Dr. Potts has focused hisknowledge of cardio-

vascular physiology on improving survivalfrom life-threatening cardiovascular emer-gencies. His interest in the practical appli-cation of emergency cardiovascular carecomes from his experience as an EMT duringand after his undergraduate training. Contacthim via e-mail at [email protected].

Tom P. Aufderheide, MD, FACEP, is a pro-fessor of emergency medicine at the MedicalCollege of Wisconsin in Milwaukee. He

founded and directs theResuscitation ResearchCenter in the Depart-ment of EmergencyMedicine. Currently amember of the BLS

Subcommittee for the National AHA’s ECCPrograms, Dr. Aufderheide has held variousleadership positions with the AHA over thepast 15 years, including BLS science editorand chair of the BLS Subcommittee.

Todd J. Crocco, MD, is an associate pro-fessor and vice chairman of the Departmentof Emergency Medicine at West Virginia

University. He alsoserves as the assistantmedical director for theHealthNet Air MedicalTransport Program forWest Virginia University

Hospitals. Dr. Crocco has served as co-chairof the American Stroke Association AdvisoryWriting Group for EMS Continuing MedicalEducation on Stroke and is a member of theAHA’s ECC Committee. Dr. Crocco also hasongoing research programs in, both, basicand clinical sciences studying the emergencytreatment of acute stroke. He has providedhis expertise in these areas for the develop-ment of the 2005 ECC Guidelines.

John Field, MD, is a professor of medicineand surgery in the Division of Cardiology atThe Pennsylvania State University, Hershey.He is board certified in internal medicine,cardiovascular care (cardiology), critical caremedicine and emergency medicine. Dr. Field

is also a senior scienceeditor for the AHA’sECC Programs. He hascontributed signifi-cantly to the 2000 and2005 Guidelines, as

well as to ACLS training materials duringthe past 10 years.

Louis Gonzales, EMT-P, has been activeas a field EMS provider and educator fornearly 20 years. He currently serves as com-

mander of the ClinicalPractices Division ofWilliamson CountyEMS in Georgetown,Texas, and adjunct fac-ulty in the Department

of EMS Professions for Temple College,Temple, Texas. His involvement in the AHA’sECC Programs include past membership onthe ECC Committee, National First AidScience Advisory Board and First Aid TaskForce. He currently serves as the senior over-sight editor for student training materials forAHA ECC Programs.

Mary Fran Hazinski, RN, MSN, is a clin-ical specialist in the Pediatric Emergency andCritical Care Department at Vanderbilt

Children’s Hospital. Sheis also a senior scienceeditor for the AHA’sECC Programs and hasserved as the co-chair ofthe AHA ECC Com-

mittee and its Pediatric Subcommittee. Shewas an editor of the 2000 Guidelines andhas contributed to ECC Guidelines andtraining materials for over 15 years. Herclinical research has focused on pediatriccritical care, child safety and use of AEDsfor pediatric patients.

Edward C. Jauch, MD, MS, FACEP, is anassistant professor of emergency medicine at the University of Cincinnati College of

Medicine, the associatedirector of research forthe Department ofEmergency Medicineand a member of the Greater Cincinnati/

Northern Kentucky Stroke Team. Dr. Jauch’sprimary area of research is in the identifica-tion and development of biomarkers in acutestroke and traumatic brain injury. He is pastchair of the Society of Academic Emergency

Medicine Neurologic Emergencies InterestGroup, and the ACEP representative to theOhio Department of Health Council on StrokeEducation and Prevention and to the AHAComprehensive Stroke Center Committee.Dr. Jauch is actively involved with the AHAsitting on the Stroke Leadership Council,Scientific Committee, and co-chairs theStroke Subcommittee of the ECC.

Arno Zaritsky, MD, serves as professorand chief, pediatric critical care, at theUniversity of Florida College of Medicine. Dr.

Zaritsky is a foundingmember and the cur-rent chair of the AHA’sECC Pediatric Subcom-mittee. He was anorganizer of the First

International Conference on PediatricResuscitation, sponsored by the AAP andAHA (1994) and chaired the PediatricÜtstein Consensus Panel in that same year.These activities directly contributed to thedevelopment and publication of the firstpediatric resuscitation guidelines in 1986,as well as their 1992, 2000 and 2005 revi-sions. Dr. Zaritsky is also credited as a co-author of the first PALS course curriculum,and as the lead author and editor for the2000 PALS Guidelines and the 2002 revi-sions to the PALS course materials. Mostrecently, Dr. Zaritsky served as one of twoevidence evaluation experts for the “2005Consensus on Science” process, making asignificant contribution to the resuscitationguidelines developed by organizationsworldwide.

Mary Newman is executive director of theSCA Network. She previously served as exec-utive director of the National Center for Early

Defibrillation and onfaculty at the Universityof Pittsburgh School ofMedicine, cardiac arrestresearcher at theKrannert Institute of

Cardiology at Indiana University School ofMedicine, and founding editor of theCitizen CPR Foundation and AHA publica-tion Currents in Emergency Cardiac Care.She is the author of Challenging SuddenDeath: A Community Guide to Help SaveLives, and has been a JEMS contributingeditor since 1980. Contact her via e-mail [email protected].


New Approach to Cardiac Incident Management

In 1974, at the time of the first publication,the scope of practice for prehospital emer-gency personnel was still quite limited forproviders in about half of the states,1 and theterm EMT-paramedic had not yet been madean “official” category of health-care providerby the federal government. (The Departmentof Health Education and Welfare and theDepartment of Transportation adopted theterm in 1975.) There was a growing aware-ness of such programs, buoyed by the 197460 Minutes story calling Seattle “the best placeto have a heart attack” and describing thecity’s Medic One program, and, of course, bythe hit television series Emergency! (1972–1977). Nonetheless, publication of the 1974Guidelines occurred in the context of a rela-tively new prehospital health-care profession.It is no surprise that the AHA Guidelines ofthat day focused on in-hospital care and pro-vided little explicit reference to Guidelineimplementation in the EMS environment.

Through the past three decades, pre-hospital care has advanced greatly in the U.S.and become a model for other countries thathave also implemented non-physician-basedEMS systems. Along with EMS systems, theAHA Guidelines have evolved, becomingmore relevant to the prehospital provider.

That is not to say that these two evolutionaryprocesses have been, at all times, coordinated.Even as recently as the 2000 Guidelines, rec-ommendations were made that were not easi-ly applied to the less controlled environmentin which EMS personnel operate. For exam-ple, the formulation (and price) of amio-darone in 2000, made it difficult to administer(and justify adding to the drug bag of everyEMS vehicle), setting aside any other contro-versy related to the drug. Even though pre-vious recommendations for high-dose epi-nephrine were applicable to all health-careproviders, that recommendation in 2000 alsocaused some difficulty for EMS providers.

The 2005 Guidelines, on the other hand,reflect a greater awareness of the prehospitalprovider than any previous versions.2 Ofcourse, this was not by accident. A concertedeffort was made by the AHA to include pre-hospital organizations and individuals in itsEmergency Cardiovascular Care Committeeand the near-perpetual guideline develop-ment process.

The 2005 Guidelines are based on anextensive, rigorous review of resuscitationscience, undertaken by the InternationalLiaison Committee on Resuscitation, ofwhich the AHA is a founding member.

Details of the evidence evaluation process aredescribed in an editorial by Zaritsky andMorley that accompanied ILCOR’s 2005Consensus on Science, published concurrentwith the electronic version of the AHA 2005Guidelines.3 Perhaps just as notable as thescope of the consensus process is theunprecedented attention that was given tomanaging potential conflicts of interest.Details of that process are described in aneditorial by Billi et al, which accompanies the2005 Guidelines publication (pp. 204–205).

In this supplement, we highlight changesto the AHA Guidelines for CPR and ECCthat affect EMS providers. Some of the rec-ommendations are directly related to resusci-tation protocols that you use. Other recom-mendations are directed at lay providers, or9-1-1 dispatchers and EMS systems. Thesechanges are presented because they have thepotential to impact specific actions taken byyou on scene or the protocols for treatmentand operations that are used in your particu-lar EMS system.

REFERENCES1. JAMA. 227(7, Supplement):837–840,

Feb. 18, 1974.2. Circulation. 112(24, Supplement):

Dec. 13, 2005. http://circ.ahajournals.org/content/vol112/24_suppl/.

3. Circulation. 112(22, Supplement): Nov. 29, 2005. http://circ.ahajournals.org/content/vol112/22_suppl/.

What’s New & Why

With the heavy emphasis placed onimproved technique and synchronization ofCPR performance, quality of CPR, limitingventilations and maintaining compressions,the message for EMS providers is that a car-diac arrest must now be managed using thesame incident management approach weuse at other major EMS incidents.

In the case of a cardiac arrest, CPR IMSdoesn’t just stand for incident managementsystem. It stands for Inflation and ventilationcontrol; Maintaining compressions with as few

interruptions as possible; and Synchronizingand choreographing the CPR process.

The CPR incident commander shouldhave a CPR incident management sheet thatstresses important ECC parameters. Someexamples: 1) Keep compressions going at allcosts, even if it means refraining from intu-bating. Compressions should not be inter-rupted for more than 10 seconds. When acrew stops compressions for any reason, theCPR IC should alert the crew at the five sec-ond mark that they have five seconds to begin

compressions. 2) Be vigilant about maintain-ing ventilations at the new rate and volume.Make sure the rescuer is not over-ventilatingthe patient. With an advanced airway inplace, the rate is now just one breath every sixto eight seconds, with each breath to last onecomplete second. Therefore, those patientscan be ventilated just once every 10 compres-sions without pausing. 3) The compressionrole must be switched every two minutes sothe quality of CPR doesn’t diminish.

New devices will help you perform betterCPR. But without a CPR IMS system, youwill not be able to maintain the synchro-nized performance of CPR that current sci-ence recommends.

—A.J. Heightman, MPA, EMT-P, Editor-in-Chief, JEMS

The 2005 American Heart association Guidelines for ECC & CPRare a milestone in the history of EMS, not just because of the amount ofscience and EMS input involved in their development, but becausethere’s an important operational message in their content.

For more than 30 years, the American Heart Association has published cardiopulmonary resuscitation (CPR) and emergency cardio-vascular care (ECC) guidelines for health-care and lay providers.


EMS PROVIDERS—BLS• Focus on providing high-quality CPR

with special attention to chest com-pression depth and rate, permittingcomplete chest wall recoil and minimal interruptions to compressions (pp. 25–26).

• All rescuers acting alone should use a 30:2 ratio of compressions-to-ventilations for all victims exceptnewborns (pp. 26–27, 160–161).

• Health-care providers performing two-rescuer CPR for adults should use a 30:2

compression-to-ventilation ratio whenthere is no advanced airway in place(pp. 26–27).

• Health-care providers performing two-rescuer CPR for infants and childrenshould use a 15:2 compression-to-ventilation ratio when there is noadvanced airway in place (p. 161).

• Compressions are given at a rate of 100per minute with complete relaxation ofpressure on the chest wall after eachcompression (pp. 26, 160).

• Once an advanced airway is in place

(e.g., endotracheal tube, CombiTube orLMA), continuous chest compressionsare given at 100/minute with one venti-lation every six to eight seconds (8–10 ventilations per minute). The ventila-tions are given without pausing chest compressions (pp. 26–27, 160–161).

• Each rescue breath should be given over one second (pp. 23, 159).

• If a jaw thrust without head extensiondoes not open the airway for an un-responsive trauma victim with suspected cervical spine injury, use the head tilt–chin lift maneuver (pp. 21–22, 157–158).

• Assessing breathing (pp. 22–23, 158)—Basic health-care providers check for “adequate” breathing in adults and “presence or absence” of breathing ininfants and children before giving rescuebreaths. Advanced providers look for“adequate” breathing in victims of all agesand are prepared to support oxygenationand ventilation.

Summary of MajorChanges

The 2005 Guidelines place great emphasis on improving the qualityof CPR delivered by all providers and on increasing the chance that a cardiac arrest victim will receive bystander CPR; both are attempts to improve the outcomes of cardiovascular medical emergencies. Thefollowing list summarizes the changes that are of significance to EMSproviders, dispatchers and system administrators. To enable furtherresearch, we direct you to specific pages of the 2005 Guidelines inCirculation, where expanded discussions of these topics can be found.

This San Diego FD team conducts coordinated resuscitation efforts with one person in charge of overall care deliverywhile others are assigned to airway control, preparation and delivery of medications, and uninterrupted rotation of compression performance every two minutes.

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• For infant and child victims, health-careproviders may, if needed, try “a coupleof times” to reopen the airway anddeliver effective breaths (i.e., breathsthat produce visible chest rise) (p. 158).

• Avoid over-ventilation: too many breathsper minute or breaths that are too largeor too forceful (pp. 23, 159).

• Use a child dose-reduction system withAEDs (e.g., pediatric pads/cable), whenavailable, for children from one to eightyears old (p. 162).

• When two or more health-care providersare present during CPR, rescuers shouldrotate the compressor role every twominutes (pp. 26, 161).

• For victims of ventricular fibrillation(VF) cardiac arrest, use a single shock,followed by immediate CPR for twominutes, starting with compressions first (p. 36).

• Actions for foreign body airwayobstruction (FBAO) relief were simplified (pp. 28–29, 162).

• In the event that a lone health-careprovider discovers an unresponsive person and there is no one to send toactivate the emergency response num-ber, the sequence of actions should betailored for the most likely cause ofarrest in victims of all ages (pp. 21, 157):“Phone first,” get the AED and return tostart CPR and use the AED for all adultsand any children who experience out-of-hospital sudden collapse. “CPR first”(provide about five cycles or two minutesof CPR before activating the emergencyresponse number) for unresponsiveinfants and children (except infants andchildren with sudden, witnessed col-lapse) and for all victims (includingadults) of likely hypoxic arrest (e.g.,drowning, injury, drug overdose).

• During two-rescuer CPR of an adult,child or infant with an advanced airwayin place, the rescuer providing rescuebreaths gives one breath about every sixto eight seconds (8–10 breaths/minute)while the compressions are deliveredcontinuously, at 100/minute, withoutpauses for ventilation (rather than incycles of compressions with pauses fortwo rescue breaths) (pp. 23, 159).

• For adult out-of-hospital cardiac arrestthat is not witnessed by the EMSprovider, rescuers may give a period ofCPR (about two minutes) before check-ing the rhythm and attempting defib-rillation (pp. 27, 35).

EMS PROVIDERS—ACLS• Recommended use of endotracheal (ET)

intubation is limited to providers withadequate training and opportunities topractice or perform intubations.Increased information about use of LMAand esophageal-tracheal combitube(CombiTube) is also included in theguidelines (pp. 52–55).

• Confirmation of ET tube placementrequires both clinical assessment anduse of a device (e.g., exhaled CO2

detector, esophageal detector device).Use of a device is part of primary confirmation of tube placement and isno longer characterized as secondaryconfirmation (p. 54).

• Intravenous or intraosseous (IO) drugadministration is preferred to endo-tracheal administration (p. 58).

• General concepts of treating pulselessarrest (i.e., VF/pulseless VT, asystole and PEA) (pp. 58–61):a. BLS skills, including effective chest

compressions with minimal inter-ruptions, are the priority skills andinterventions for cardiac arrest.

b. Insertion of an advanced airway maynot be a high priority.

c. Organize care to minimize inter-ruptions in chest compressions forrhythm check, shock delivery,advanced airway insertion or vascular access.

• Treatment of VF or pulseless VT (pp. 59–63):a. To attempt defibrillation, deliver one

shock (using monophasic or biphasicwaveforms) followed immediately byCPR (beginning with chest compres-sions). Do not attempt to palpate apulse or check the rhythm after shockdelivery.

b. After about two minutes of CPR if an organized rhythm is apparent during rhythm check, the providerchecks a pulse.

c. With a biphasic defibrillator (pp. 36),it is reasonable to use selected ener-gies of 150 J to 200 J with a biphasictruncated exponential waveform or120 J with a rectilinear biphasic wave-form for the initial shock. For secondand subsequent shocks, use the sameor higher energy. If you are operatinga manual biphasic defibrillator andare unaware of the effective doserange for that device to terminate VF,you may use a selected dose of 200 J

for the first shock and an equal orhigher dose for the second and sub-sequent shocks.

d. With a monophasic defibrillator (pp. 36), select a dose of 360 J for all shocks.

e. Drugs should be delivered duringCPR, as soon as possible after rhythmchecks. If a third rescuer is available,that rescuer should prepare drugdoses before they are needed. If arhythm check shows persistentVF/VT, the appropriate vasopressor orantiarrhythmic should be adminis-tered as soon as possible after therhythm check. It can be administeredduring the CPR that precedes (untilthe defibrillator is charged) or followsthe shock delivery. The timing of drugdelivery is less important than is theneed to minimize interruptions in chestcompressions.

f. Vasopressors are administered whenan IV/IO line is in place, typically ifVF or pulseless VT persists after thefirst or second shock. Epinephrinemay be given every three to five min-utes. A single dose of vasopressin maybe given to replace either the first orsecond dose of epinephrine.

g. Antiarrhythmics may be consideredafter the first dose of vasopressors(typically if VF or pulseless VT per-sists after the second or third shock).Amiodarone is preferred to lidocaine,but either is acceptable.

This crew is ventilating without pausing compressions, delivering just eight ventilations per minute.

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• Treatment of asystole/pulseless electricalactivity: Epinephrine may be adminis-tered every three to five minutes. Onedose of vasopressin may replace eitherthe first or the second dose of epineph-rine (pp. 61–63).

• Treatment of symptomatic bradycardia:The recommended atropine dose is now0.5 mg IV, which may be repeated to atotal of 3 mg (pp. 68–69).

• Treatment of symptomatic tachycardia:A single, simplified algorithm includessome, but not all, drugs that may beadministered. The algorithm indicatestherapies intended for use in the in-hos-pital setting with expert consultationavailable (pp. 69–76).

• Initial general therapy for acute coro-nary syndrome (ACS) (pp. 89–93):a. Administer oxygen to all patients

with overt pulmonary congestion orarterial oxygen saturation <90%.

b. Unless the patient has a knownaspirin allergy, administration of asingle chewed dose of aspirin(160–325 mg) is recommended for allpatients with suspected ACS, as soonas possible.

c. Patients with ischemic discomfortmay receive sublingual or aerosolnitroglycerin, repeated twice at five-minute intervals until pain is relievedor low blood pressure limits its use.

d. Administer morphine sulfate forcontinuing pain unresponsive tonitrates. Start with a 2–4 mg IV dose,and give additional doses of 2–8 mgIV at five- to 15-minute intervals.

EMS PROVIDERS—PALS• Apply health-care provider “child”

CPR guidelines to victims from one year of age to the onset of puberty (previously, they were applicable forages one to eight years) (p. 157).

• Confirming ET tube placement requires clinical assessment (e.g., visualization of vocal cords and aus-cultation of bilateral breath sounds) and detection of exhaled carbon dioxide (CO2) (p. 169).

• Confirmation of ET tube placementmust be verified when the tube is in-serted, during transport and wheneverthe patient is moved (p. 181).

• Esophageal detector devices may beused in children weighing > 20 kg whohave a perfusing rhythm (p. 169).

• An LMA is an acceptable alternative toestablish a “protected” airway whenused by experienced providers (p. 167).

• During two-rescuer CPR of a child orinfant with an advanced airway in place,the rescuer providing rescue breathsgives one breath about every six to eightseconds (8–10 breaths per minute)while the compressions are deliveredcontinuously at 100/minute withoutpauses for ventilation (pp. 168, 175).

• Vascular routes (IV/IO) are preferred to endotracheal drug administration (p. 170).

• IO placement is an acceptable alterna-tive for vascular access in children of allages (p. 170).

• Timing of one shock, CPR and drugadministration during pulseless arresthas changed and now is identical to thatfor ACLS (pp. 174–175).

• Routine use of high-dose epinephrine isnot recommended (p. 174).

• Vasopressin is not recommended inpediatric cardiac arrest (p. 172).

• Lidocaine is deemphasized and amio-darone is considered the drug of choicefor shock-refractory VF/pulseless VT,but lidocaine can be used for treatmentif amiodarone is not available (pp. 171–172).

• Termination of resuscitative efforts is discussed in the Guidelines. Although previously used as an

indicator of futility, there are reports of intact survival following prolongedresuscitation and absence of spontaneous circulation despite twodoses of epinephrine (pp. 7, 181).

EMS DISPATCHERS &SYSTEM ADMINISTRATORS• Dispatchers should receive appropriate

training in providing prearrival tele-phone CPR instructions to callers (p. 20).

• Dispatchers who provide telephone CPRinstructions to bystanders treating children and adult victims with a highlikelihood of an asphyxial cause ofarrest (e.g., drowning) should givedirections for rescue breathing followedby chest compressions. In cases that arelikely sudden cardiac arrest (SCA), tele-phone instruction in chest compressionsalone may be preferable (pp. 20, 27).

• Dispatcher CPR instruction programsshould develop strategies to helpbystanders identify patients with occa-sional gasps as likely victims of cardiacarrest (p. 20).

• The EMS system’s quality improvementprogram should include periodic reviewof the dispatcher CPR instructions pro-vided to specific callers (p. 20).

• Dispatchers should advise patients (with no history of aspirin allergy orsigns of active or recent gastrointestinalbleeding) to chew an aspirin (160–325 mg) while awaiting the arrival ofEMS providers (p. 91).

• EMS system medical directors may con-sider implementing a protocol thatwould allow EMS responders to provideabout five cycles (about two minutes) ofCPR before attempted defibrillationwhen the EMS system call-to-responseinterval is longer than four to five minutes (p. 35).

• Prehospital 12-lead ECG (p. 91):a. Implementation of out-of-hospital

12-lead ECG diagnostic programs is recommended for urban and suburban EMS systems.

b. Routine use of 12-lead out-of-hospitalECG and advance notification is recommended for patients with signsand symptoms of acute coronary syndromes (ACS).

c. It is recommend that paramedicsacquire and transmit either diagnostic-quality ECGs or their interpretationof them to the receiving hospital prior to arrival.

The use of continuous EtCO2 moni-toring via a digital readout on the ECGmonitor assures the crew that CO2 ispassing through the ET tube.

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• Out-of-hospital administration of fibrin-olytics to patients with ST-elevationmyocardial infarction (STEMI) (pp. 91–92):a. Given the operational challenges

required to provide out-of-hospitalfibrinolytics, most EMS systemsshould focus on early diagnosis with12-lead ECG, rapid transport andadvance notification of the ED (verbalinterpretation or direct transmissionof ECG) instead of prehospital deliv-ery of fibrinolytic agents.

b. Prehospital fibrinolytic agent admin-istration is, however, safe (assumingno contraindications), feasible andreasonable and may be performed bytrained paramedics, nurses and phys-icians for patients with symptomduration of 30 minutes to six hours.

c. If such a program is implemented,system requirements include proto-cols with fibrinolytic checklists detail-ing indications and contraindications;ECG acquisition and interpretation;experience in advanced ACLS; theability to communicate with thereceiving institution; a medical direc-tor with training/experience in man-agement of STEMI; and a process ofcontinuous quality improvement.

• Out-of-hospital triage of suspected orconfirmed STEMI (p. 92): At this time

there is inadequate evidence to recom-mend out-of-hospital triage to bypasshospitals that cannot provide percuta-neous coronary intervention (PCI) tobring patients to a PCI center. Local pro-tocols for EMS providers are appropriateto guide the destination of patients withsuspected or confirmed STEMI.

• Stroke patients who require hospitaliza-tion should be admitted to a facilitywith a dedicated stroke unit (staffed bya multidisciplinary team experienced inmanaging stroke), when one is availablewithin a reasonable transport interval(pp. 21, 111–113).

• Improvement in response intervalsshould be made, when feasible (p. 19).

LAY RESCUERS• In the unresponsive victim who is not

moving, do not check for signs of circu-lation. After delivery of two rescuebreaths, immediately begin chest com-pressions (and cycles of compressionsand rescue breaths) (pp. 21–27).

• Do not deliver rescue breathing withoutcompressions (pp. 25–27).

• Use a 30:2 compression:ventilation ratioand a compression rate of 100/minutefor victims of all ages.

• When recommended by an AED, lay rescuers should deliver one shock followed by immediate CPR beginning

with chest compressions. All rescuersshould allow the AED to check the victim’s rhythm again after about fivecycles (about two minutes) of CPR (p. 36).

• Continue AED/CPR cycles until the person is awake or until EMS takes over (p. 36).

• For the lay rescuer, a child is defined asup to eight years old, which is differentfrom the definition used by health-careproviders (i.e., up until the victim hassigns of puberty) (pp. 13, 157). If alonewith an unresponsive infant or child,give about five cycles of compressionsand ventilations (about two minutes)before leaving the child to phone 9-1-1(pp. 14, 157).

• Do not try to open the airway using a jaw thrust for injured victims—use the head tilt–chin lift for all victims (pp. 21, 157).

• First aid providers may help victimswith asthma use an inhaler prescribedby a physician (p. 197).

• First aid providers may help victimswith a bad allergic (anaphylactic) reac-tion use a prescribed epinephrine auto-injector. The first aid provider mayadminister the epinephrine if theprovider is trained to do so, the statelaw allows it, and the victim is unable toadminister it (p. 197).

Confirmation of ET tube placement requires both clinical assessment and use of a CO2 detector or EDD. Use of such adevice is now part of primary confirmation of tube placement and is no longer characterized as secondary confirmation.

Summary of Major Changes

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BASIC LIFE SUPPORTCompressions: The 2005 recommenda-tions for compressions have, sometimes,been summarized as, “Push hard, push fast,allow the chest to fully recoil, and minimizeinterruptions.” For many professional EMSproviders, that might really mean, “Pushharder, push faster, allow the chest to fullyrecoil, and stop only to use a bag mask toventilate the patient, analyze the rhythm,deliver a shock or intubate. When such aninterruption to compressions occurs, keepthe length of that interruption to anabsolute minimum. For example, take nolonger than 10 seconds for any singleattempt at intubation.

Providing compressions with minimuminterruption should be foremost in theminds of all team members but especiallythe person who is taking a turn at givingcompressions. That team member shouldvery closely track the seconds that elapsewhenever compressions are interrupted forany reason. Once five seconds have passed,he or she should warn the other team mem-ber(s) and by 10 seconds, compressionsshould have begun again. This sort of prac-ticed and rigorous routine will reduce thechance that rescuers will fall victim to“adrenaline-rush time-warp effect” andunintentionally prolong the interruptions.

That brings us to compression-ventilationratios. A ratio of 30:2 has been recommend-ed for all rescuers (lay or health-careprovider) who are acting alone in a resusci-tation attempt of victims of all ages (exceptfor newly born). You, as an EMS provider,would not likely be acting alone, unless youare off duty. So it is more useful to considerhere the recommendations for CPR whenperformed by more than one professionalrescuer. In this case, the recommended ratio

for children and infants differs from adults.Use 15:2 on children and infants and con-tinue to use 30:2 on adults.

Both of these new ratios for compressionsto ventilations reflect a very significant jumpfrom the previous Guidelines, and you maybe wondering what could have brought onsuch a dramatic change. The primary factorsthat drove the ratio up are:

1. Interruptions of compressions for anyreason result in a reduction of thetotal number of compressions deliv-ered in any given unit of time. Forexample, the old ratios for adults andchildren would result, under the bestof circumstances, in only about 50compressions being delivered to anadult in a minute and 60 to a child.

2. It takes a number of chest compres-sions to raise the pressure in the coro-nary arteries to a level that provides areasonable amount of blood supply tothe heart muscle, itself, and keep ithealthy. That pressure drops rapidlywith each pause, requiring the firstfew compressions in the next set tobuild that pressure back up. So fewerpauses means that more of the totalcompressions delivered will be effec-tive, rather than being used to buildthe pressure back up.

3. Recent research has documented thateven health-care professionals intro-duce long and frequent interruptionsin chest compressions and that areduction in the proportion of thetime that they spend compressingresults in a decrease in the chancethat the patient will have a return ofspontaneous circulation.

4. A higher ratio reduces the number ofventilations given over time but that

is not as bad as it might seem.Ventilations are relatively less impor-tant during the first minutes of CPRfor victims of a sudden arrhythmia-induced cardiac arrest (VF or pulse-less ventricular tachycardia) than theyare after asphyxia-induced arrest(drowning or respiratory failure dueto disease). Even with asphyxialarrest victims, though, their require-ment for oxygen is lower than nor-mal. That is true for two reasons.First, the amount of blood that isbeing pumped by the chest compres-sions is lower than normal. So theamount of oxygen that can be “pickedup” by the blood in the lungs is also alot lower than normal (no need toprovide more breaths than is warrantedby the blood flow that is there).Secondly, when cardiac arrest occurs,the body’s metabolism really slows; itsimply does not use as much oxygen.

5. For lay rescuers, a single compression-ventilation ratio (30:2) for all agegroups greatly simplifies the instruc-tions for performing CPR. Thisshould reduce confusion about howto do CPR and increase the level ofconfidence of potential providers ofCPR. Because it is easier to rememberthe rules, this change may increasethe number of bystanders who youencounter performing CPR when you arrive.

Maintaining adequate compression depth(1.5 to 2 inches for an adult) and rate (100compressions/minute), and consistentlyallowing the chest to fully recoil betweencompressions is very fatiguing. The 2005Guidelines recommend that health-careprofessionals swap duty as compressorevery two minutes. With the adult patientwho has no advanced airway in place, thatwould be every fifth cycle of 30:2 CPR (seeFigure 1, p. 15). For children with noadvanced airway in place, that would beabout every 10th cycle of 15:2 CPR.

The 2005 Guidelines also provide recom-

Revising YourProtocols

Now that we’ve reviewed specific 2005 CPR and ECC Guidelineschanges that affect EMS, it’s time to address ways to incorporate thesechanges into your protocols. Below, we discuss recommended changesfor EMS providers, dispatchers and system administrators, as well aslayperson training and procedures.


mendations on the use of devices that sup-port or enhance the circulation that is gen-erated during CPR (pp. 46–49). Most ofthem are related to mechanical compression(like the Michigan Instruments Thumper).The most significant changes in this part ofthe Guidelines since 2000 are found in thediscussions of two devices.

The first is the load-distributing band(LDB). This is a circumferential chest com-pression device composed of a pneumaticallyactuated constricting band and backboard.In the 2000 guidelines, the predecessor tothis device was discussed as “vest CPR” andits use was given a class IIb recommenda-tion (although no device was commerciallyavailable at the time). The class of recom-mendation for the more recently developedLDB is also a class IIb. This device may bemore familiar to you by its proprietaryname, the AutoPulse (originally manufac-tured by Revivant, which is now owned byZOLL Medical Corp.). Since the conclusionof the evidence-evaluation process for the2005 Guidelines, reports from two clinicalstudies of the AutoPulse in the prehospitalsetting have been presented as abstracts.One of the two studies showed positiveresults when comparing AutoPulse withstandard CPR and the other showed nega-tive results. It is likely that further studieswill be conducted to resolve this apparentdifference in performance.

The only device for which there was asignificant change in the 2005 version ofthe Guidelines is the impedance thresholddevice (ITD). Unlike all of the other devicesin this section of the Guidelines, the ITDdoes not operate by compressing the chest.It is used to enhance venous return duringchest compressions by lowering theintrathoracic pressure. Also, the ITD is theonly device listed in this section that wasassigned a class IIa recommendation(upgraded from the class IIb recommenda-tion made in 2000). All of other devices inthis section were given a class IIb or classindeterminate recommendation. The ITDmay be more familiar to you by its tradename, the ResQPOD (manufactured byAdvanced Circulatory Systems Inc.). The2005 Guidelines state that, “when the ITDis used by trained personnel as an adjunctto CPR in intubated adult cardiac arrestpatients, it can improve hemodynamicparameters and ROSC” (return of sponta-neous circulation). Some recent researchsuggests that use of the ITD with a facemask may also create the same negative

intratracheal pressure as occurs when theITD is used with an ET tube, if rescuers canmaintain a tight face mask seal (p. 48).

Ventilations: The 2005 Guidelines focuson ventilation rate, duration and volume dur-ing CPR for a number of fundamental rea-sons. Perhaps the most important is thatless ventilation than normal is needed duringCPR. For optimal oxygenation of the bloodand elimination of carbon dioxide, ven-tilation should closely match blood flowthrough the lungs (the so-called “ventilation-perfusion ratio”). During CPR, blood flowthrough the lungs is only 25–33% of normal.Thus, significantly less ventilation (fewerbreaths and smaller tidal volumes) is requiredto match the reduced blood flow that chestcompressions generate (pp. 23, 27).

Another consideration that drives thecurrent recommendations for ventilation isthe recognition that the increased pressurewithin the chest caused by positive pressureresuscitation breaths reduces venous returnto the heart. Because venous return deter-mines cardiac output, reduced venousreturn means cardiac output is reduced and,thus, delivery of oxygen to tissues in thebody is also reduced. An excessive numberof ventilations, prolonged ventilation dura-tion or high tidal volumes only increase theamount of time during which venous returnis reduced. This can be harmful or evendeadly (p. 23).

A third consideration is quite intuitive:

When chest compressions are interrupted,all blood flow ceases. Delivery of ventila-tions has been shown to be responsible fora significant component of the hands-offtime during a resuscitation attempt (thetime during which chest compressions arenot being performed). Hands-off timeapproaches 50% of CPR duration in someEMS systems (p. 26). It is unreasonable toexpect a successful outcome when forwardblood flow is absent during half of a resus-citation. It stands to reason, then, thatblood flow should be prioritized over ven-tilations. The 2005 Guidelines reflect thatphilosophy.

Ventilation rate: Slow down! That is theoverriding message for all health-careproviders when it comes to ventilation. Thetendency to over-ventilate (too many andtoo much) is not peculiar to prehospitalproviders, but some startling data that werecollected during EMS rescues have demon-strated that there is a significant differencebetween the way professional rescuers per-form CPR in the classroom and the waythey deliver CPR on scene at an actual car-diac arrest. Experience has shown that inthe heat of the moment, several commonmistakes are made during CPR, includingventilating too frequently or deliveringbreaths with prolonged ventilation dura-tion. Therefore, despite high-quality educa-tion and training, additional steps toensure adherence to guidelines are likely to

The ResQPOD impedance threshold device is placed between the ET tubeand a ventilation device and lowers the intrathoracic pressure which, in turn,enhances venous return during chest compressions. It also features LED lightsthat flash in accordance with the new, slower, AHA-recommended ventilation rate.


be needed (pp. 23, 25).EMS providers may employ various tech-

niques to better pace their delivery of venti-lations. Perhaps the most elegant and cost-effective method is to simply train rescuersto use an existing cue: compressions.

Prior to establishing an advanced airway,simply adhering to the recommendedcompression-ventilation ratio of 30:2(adults) or 15:2 (infants and children whentwo rescuers are working together) reducesthe likelihood of excessive ventilation, pro-vided that ventilations are delivered at onesecond per breath and tidal volume is nogreater than that required to produce visiblechest rise. It is important to note thathyperventilation has not been reported inevery published study. A ventilation rate of11/minute was reported by one researchgroup who studied prehospital resuscita-tions.1 When asked how EMS rescuers weretrained to avoid hyperventilation, Wiknoted that the rescuers practice compres-sions and ventilations with manikins on aregular basis to ensure that compressionand ventilation rates delivered are accurate.

Following establishment of an advancedairway, compressions and ventilations areno longer delivered in cycles, with pauses inchest compressions to deliver ventilations.The compressing rescuer should delivercompressions at a rate of 100/minute with-out pauses (except as needed for suchactions as rhythm check or shock delivery).The rescuer should deliver no more thaneight- to 10-breaths/minute (the recom-mended rate for adults, children and infantswith an advanced airway in place), withoutattempting to synchronize breaths betweencompressions. There should be no pause inchest compressions for delivery of ventila-tions. If chest compressions are deliveredcontinuously at the correct rate of 100 com-pressions per minute, then that is a reason-able way to gauge the timing of ventilations;deliver a breath no more often than onceevery 10th compression. This will provide aventilation rate no greater than 10 breathsper minute.

Devices offer another solution to main-taining an appropriate ventilation rate. Endtidal CO2 waveform monitoring providesanother method to assist EMS providers indelivering the correct number of ventilationper minute. Some manufacturers of otherEMS equipment, such as defibrillators, areimplementing technology that electronicallymonitors the quality of CPR delivered to acardiac arrest victim, including ventilation

rate. That technology provides real-timefeedback to rescuers and can be used tosupport quality improvement programs.Another device, the impedance thresholdvalve, attached to an advanced airway, isdemonstrated to improve hemodynamicsduring CPR and has ventilation timinglights that flash 10 times per minute for onesecond every flash. The use of this devicemay not only improve the effectiveness ofcompressions, but assist rescuers in consis-tently providing ventilations according toAHA recommendations for breaths perminute with an advanced airway in place.

Ventilation volume: Studies in humanswith normal perfusion suggest that a tidalvolume of 8–10 mL/kg maintains normaloxygenation and elimination of CO2.However, during CPR, perfusion is only25–33% of normal. As a result, lower thannormal tidal volume and respiratory ratecan maintain effective oxygenation andventilation during CPR. During adult CPR,that means a tidal volume of approximately500–600 mL (6 to 7 mL/kg) (p. 23).Because it is not possible to accurately esti-mate tidal volume, the simplified guidelinesfor the volume of ventilations provide a sin-gle rule to follow for all victims: Deliverenough air to make the chest rise, and do thatover about one second. This includes rescuebreaths delivered both prior to and afterestablishing an advanced airway. This rec-ommendation is designed to simplify train-ing, reduce the incidence of prolonged ven-tilation duration (and therefore the timeduring which there is increased pressurewithin the chest) and (when no advancedairway is in place) limit the length of theinterruption in compressions that isrequired to deliver ventilations.

Ventilation devices: Insertion of anadvanced airway may not be a high priorityduring the initial stages of resuscitation.Rescuers should be aware of the risks andbenefits of insertion of an advanced airway.Because insertion of an advanced airwaymay require interruption of chest compres-sions for a considerable period of time, therescuer should weigh the need for compres-sions against the need for insertion of anadvanced airway. Airway insertion may bedeferred until several minutes into theattempted resuscitation (p. 52).

Once inserted, providers should immedi-ately perform a thorough assessment of ETtube position. This assessment should notrequire interruption of chest compressions,and includes physical examination and use

of a device that can reliably indicate incor-rect placement. Assessment by physicalexamination consists of visualizing chestexpansion bilaterally and listening over theepigastrium (breath sounds should not beheard) and the lung fields bilaterally(breath sounds should be equal and ade-quate). If there is doubt about correct tubeplacement, use the laryngoscope to visual-ize the tube passing through the vocalcords. Assessment of tracheal tube positionmay also be confirmed by use of exhaledCO2 detection or an esophageal detectiondevice. If still in doubt, remove the tube andprovide bag-mask ventilation until the tubecan be replaced (p. 54).

Before an advanced airway is placed (orinstead of placing an advanced airway) pro-fessional rescuers typically use bag-maskventilation. It is a challenging skill thatrequires considerable practice for compe-tency. A tight seal between the bag-maskand the face is best achieved with two res-cuers managing the airway. One rescueropens the airway and seals the mask to theface using a two-handed technique whilethe other squeezes the bag. Of course, res-cuers won’t have the luxury of two peopleto manage ventilation on every call. If onlyone rescuer is available to manage the air-way, a two-handed technique can still beused if the chest compressor squeezes thebag between cycles of chest compressions(pp. 51–52).

Insertion of advanced airway devices,such as the LMA and the esophageal-tracheal CombiTube, is currently within thescope of BLS practice in a number ofregions (with specific authorization frommedical control). These devices may pro-vide acceptable alternatives to bag-maskdevices for health-care providers who arewell trained and have sufficient experienceto use them. It is not clear that these devicesare any more or less complicated to usethan a bag-mask device (p. 53).

Defibrillation: New recommendationsregarding integration of CPR and defibrilla-tion are designed to optimize use of thesetherapies for any given victim. The two areasthat are most dramatically changed for EMSare the use of CPR before defibrillation insome cases (“Shock first vs. CPR first”) and,for all patients, the elimination of “threestacked shocks” in favor of a “one-shockprotocol.”

Shock first vs. CPR first—Make no mis-take about it, if you witness an arrest, youshould check the patient’s rhythm and


shock, if needed, without delay. That is thetreatment of choice for short duration VF. Apositive effect of performing some CPRbefore attempting defibrillation, though,has been observed for out-of-hospitalarrests among patients for whom the EMSresponse times were greater than four to fiveminutes. In those cases, 1.5 to 3 minutes ofCPR before defibrillation improved thechance of a return of spontaneous circula-tion and the chance of survival. One way tothink about why “CPR first” would some-times be more effective than “defibrillation

first” is captured in a 2002 article byWeisfeldt and Becker.2 The authors pro-posed that untreated cardiac arrest patientsmight pass through three phases over thefirst few minutes after their arrest: electri-cal, circulatory and metabolic phases. Eachreflects a different physiological state andrequires a different action or sequence ofactions to optimize the resuscitationattempt. Within about four minutes isthought to be the “electrical” phase of anarrest. The heart is most likely in VF andwill most often respond to immediate “elec-

trical” therapy. From four to 10 minutes isreferred to as the “circulatory” phase, whenVF is “fine” or absent. Some period of effec-tive circulation delivers much needed oxy-gen to hypoxic tissues and improves thechance of a successful defibrillation. By 10minutes after an arrest, an accumulation ofmetabolic byproducts throughout the bodymake CPR and defibrillation, alone, lesslikely to be effective. Additional therapiesare being studied that may enhance resusci-tation efforts for patients in this phase ofcardiac arrest.

Backed by some of the same evidencethat supports that three-phase model of car-diac arrest (as well as other data), the AHArecommends that you (EMS personnel)may provide two minutes of CPR beforechecking the rhythm and attempting defib-rillation when you encounter an adult vic-tim whose arrest you did not witness. Itwould be up to the medical director of yourEMS system to determine how such a pro-tocol would be implemented. Perhaps useof “CPR first” (or not) would be linked toresponse time. If, though, the system’s meanresponse time is much greater than fourminutes, it could be that the medical direc-tor would decide that all adult patientsfound in cardiac arrest would receive “CPRfirst.” Be sure to discuss this one with yoursystem administrators (p. 35).

One-shock protocol—The 2005 Guidelinesrecommend treatment of VF or pulselessVT with delivery of single shocks followedby immediate CPR, beginning with chestcompressions. This new recommendation isbased on the following evidence derivedfrom clinical evaluation of biphasic defibril-lators and from AED recordings:

• Biphasic defibrillators have a highfirst-shock success.

• Current AEDs require a long periodafter each shock to analyze therhythm to determine if subsequentshocks are needed; with current AEDs this requires interruption ofchest compressions.

• Perfusing rhythms are not often present immediately after defibril-lation (shock elimination of VF); the post-shock myocardium will benefit from CPR.

The guidelines previously (2000 and ear-lier) recommended provision of up to three“stacked” shocks without intervening CPRfor persistent VF. This recommendation wasbased on the relatively low first-shock effi-cacy of monophasic defibrillators and their

Revising Your Protocols

Figure 1: Adult BLS Health-Care Provider Algorithm (Note: Boxes bordered with dotted lines indicate actions or steps performed by the health-care provider but not the lay rescuer.) Source: Circulation. 112(24, Supplement): Dec. 13, 2005.


prevalence in the field at that time. VF couldpersist in 40% or more of the patients after asingle shock, and successive shocks werethought to lower transthoracic impedanceand increase current delivery and shock effec-tiveness. Biphasic defibrillators have a muchhigher first-shock efficacy than monophasicdefibrillators; most biphasic defibrillatorshave a first-shock efficacy > 90%. They arealso more commonly used in the field now.Thus, VF is less likely to be present after

delivery of a single shock (p. 36).When AEDs are used for defibrillation,

current models can require a long post-shock hands-off interval to analyze thepost-shock rhythm and determine if sub-sequent shocks are needed. Evaluation ofcommercially available AEDs has reportedthat they can require analysis (hands-off)periods of 37 seconds or longer to recom-mend shock or CPR. Because chest com-pressions are not delivered during periods

of analysis and (as discussed below) spon-taneous circulation is not likely to havereturned at this point, there is no bloodflow during these periods. This post-shock interruption in blood flow is dif-ficult to justify when we already knowthat VF will likely have been eliminated (> 90% of the time).

That explains the elimination of thepost-shock rhythm analysis, but why fol-low the shock with two minutes of CPR if

Figure 2: ACLS Pulseless Arrest Algorithm Source: Circulation. 112(24, Supplement): Dec. 13, 2005.


VF is most likely gone? Most patients donot demonstrate a perfusing rhythm aftershock delivery; as noted, VF is not oftenpresent. Asystole or pulseless electricalactivity are the most common rhythms. Inone recent report of 67 victims of VF car-diac arrest, none demonstrated a perfusingrhythm after shock delivery, 16% demon-strated persistent VF, and 84% demon-strated asystole or pulseless electricalactivity.3 Therefore, CPR is needed for sev-eral seconds or minutes following success-ful defibrillation to maintain blood flow tothe heart, brain and other organs until aperfusing rhythm returns. If VF is noteliminated by shock delivery, the VF islikely of low amplitude, indicating thatthe myocardium is deprived of oxygenand nutrients. (The victim is in the “cir-culatory phase” of cardiac arrest.) CPR(especially chest compressions) can deliv-er oxygen and nutrients to the myocardi-um, increasing the VF amplitude andmaking it more likely to be eliminated bythe next shock. Thus, immediate CPRafter shock delivery will be beneficialwhether VF is present or not.

Rescuers should practice with the defib-rillator that they use clinically, and withmanikins and fellow rescuers to coordinateshock delivery and CPR to minimize inter-ruptions in chest compressions needed forattempted defibrillation. Ideally, one res-cuer provides CPR while the second res-cuer retrieves the defibrillator, turns it onand attaches defibrillator pads. The res-cuer delivering chest compressions shouldcontinue compressions until the AED isready to analyze the rhythm; if a manualdefibrillator is used, the rescuer shouldperform compressions until the rhythmcan be analyzed. Once a shockable rhythmis detected, if a manual defibrillator withadhesive pads is used, the rescuer per-forming compressions should resumecompressions until the manual defibrilla-tor is charged (when practical); then therescuers should quickly “clear” the victimand deliver a shock, and a rescuer shouldimmediately resume compressions andprovide CPR for two minutes.

During cardiac arrest, rescuers shouldanalyze the victim’s rhythm about everytwo minutes. This will be after about fivecycles of CPR for an adult victim with noadvanced airway in place. The AHA antic-ipates that AED manufacturers will facili-tate reprogramming of their AEDs toprompt the rescuer and analyze the

rhythm every two minutes. In general, BLS rescuers should contin-

ue CPR and use of an AED until the victimstarts to move (indicative of a perfusingrhythm) or ALS providers take over. Ingeneral, ALS providers should not inter-rupt chest compressions to check for apulse unless the provider observes anorganized rhythm (regular QRS complex-es) on a monitor. Then the provider willcheck for a pulse. These general recom-mendations and the one-shock protocolmay be modified by a physician in special-

ized settings where continuous (e.g., elec-trocardiographic or hemodynamic) moni-toring is in place.

Energies: When an AED is used, theenergy provided by the AED is determinedby the manufacturer. The one way that res-cuers may alter the dose is through the useof a child pad-cable system or a child keyor other adjustment that allows the rescuerto reduce the shock dose for use in chil-dren ages one to eight years old. If the AEDused is capable of such adjustment, therescuer must be sure to use the system to


The 2005 AHA Guidelines recommend the routine use of 12-lead ECG andadvance hospital notification for patients with signs and symptoms of acute coronary syndromes.

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deliver a reduced shock dose only for chil-dren under eight years old; if a child sys-tem is not available, the rescuer should usea standard AED and adult AED pads. Therescuer should use the “adult” dose (usingadult pads or standard AED) for all victimsof cardiac arrest who are eight years of age(and approximately 25 kg in weight orabout 117 cm in length) and older, andshould not use the child system for thisage group (p. 39).

Commercially available AEDs providefixed or escalating energy using either amonophasic or a biphasic (either biphasictruncated exponential or rectilinear bi-phasic) waveform. Lower-energy biphasicwaveform shocks have equivalent or highersuccess for elimination of VF thanmonophasic waveform shocks. There hasbeen no direct comparison of biphasicwaveforms so no claim of superiority of anybiphasic waveform over another, or of non-escalating versus escalating energy biphasicwaveform defibrillation is supported by theevidence evaluated in 2005 (pp. 36–37).

If a manual defibrillator is used, the res-cuer should be familiar with that defibrilla-tor and with the dose at which that defibril-lator waveform has been shown to be effec-tive at elimination of VF. The AHA recom-mends that defibrillator manufacturers dis-

play the device-specific effective dose rangeon the front of each device. No singlebiphasic dose can be recommended becauseeach of the two biphasic waveforms havebeen shown to be effective in eliminatingVF at different selected energies. In general,for a first shock, selected shock energies of150 J to 200 J with a biphasic truncatedexponential waveform or 120 J with a recti-linear biphasic waveform are appropriate. Ifthe rescuer does not know the device-specific effective dose, a default dose of 200 Jmay be used, but this dose is selected bydefault because it can be delivered by allAEDs manufactured in 2005—it is not asuperior dose. For second and subsequentdoses, the rescuer should use a dose equalto or higher than the first dose (pp. 39–40).

Acute coronary syndromes: BLS health-care providers are often the first EMS per-sonnel to encounter a patient with a poten-tial acute coronary syndrome or ACS.Commonly known as a “heart attack,” ACSis a group of disorders that share in com-mon the rupture of a lipid-filled plaque in acoronary artery. This begins a series ofevents that causes clot formation in theartery and interruption of blood flow to theheart muscle. Both BLS and ALS providersplay roles in achieving the major goals oftherapy for ACS patients defined in the

2005 Guidelines. These are:• Treat acute life-threatening complica-

tions, such as VF.• Reduce heart muscle damage by

speeding time to opening of the coro-nary artery.

• Prevent or reduce major complica-tions of ACS, such as heart failure.

An important first step for BLS health-care providers is the recognition of thesymptoms possibly caused by an ACS.Treatment offers the greatest potential ben-efit, early in the course of ACS, particularlywhen complete occlusion of an artery hasoccurred. This involves recognition of pos-sible ACS symptoms, activation of localEMS chest pain protocols (see ACLS andEMS Administrative sections) and advancenotification of the receiving facility.

Classically, typical chest discomfort isdescribed as a pressure or tightness in thecenter of the chest (substernal area) andmay be associated with nausea, vomiting,sweating, light-headedness, or near faintingor fainting (syncope). The chest discomfortmay radiate to the jaw and one or bothshoulders and down the arms (usually left).These typical symptoms are usually recog-nized by BLS health-care providers. In ad-dition, all providers must also realize thatatypical symptoms may be present.

Figure 3: Ventricular Fibrillation & Pulseless VT—Treatment Sequences for ACLS & PALSSource: Currents. 16(4): 2005.


Although chest discomfort is the presentingprimary symptom in both men and women,women have more atypical symptoms thanmen. Atypical symptoms may also predom-inate in the elderly and diabetics. The sud-den onset of unexplained shortness ofbreath, weakness or fatigue are examples ofatypical symptoms.

Once a potential ACS is recognized, BLSproviders can speed the diagnosis and initi-ate treatment of the possible ACS patient inthe following ways (pp. 97–98):

• Administer oxygen to all patientswith suspected ACS. Initiate supple-mentary oxygen at 4 L/min by nasalcannula; titrate to achieve oxygen sat-uration ≥ 90%.

• If the patient has not taken full-doseaspirin, have the patient chew160–325 mg non-enteric aspirin,unless true allergy or recent gastroin-testinal bleeding has occurred.

• If the patient has been prescribed sub-lingual nitroglycerin, give (or com-plete giving) as many as three nitro-glycerin doses (tablet or spray) ifblood pressure and heart rate permit.

• Half of the patients who die suddenlyfrom ACS do so before they reach ahospital. Although a VF/VT arrest isuncommon during transport, be pre-

pared to use an AED or defibrillator.Once ALS personnel arrive, assist

providers in completing appropriate pre-hospital care (see below).

Stroke: In the realm of stroke care, thenew guidelines emphasize the importanceof stroke patient recognition, priority dis-patch and rapid transport to an appropriatehealth-care facility capable of caring forstroke patients. Although most of the criti-cal actions to be provided by EMS person-nel have not been changed, the need forefficient assessments and early communica-tion with destination hospitals is alsounderscored.

Regardless of the level of prehospitalcare provided, triage policies should beproactively established in order to guideEMS personnel’s transport decisions. Suchtriage policies will likely require inputfrom EMS medical directors, physicians,hospital administrators and any otherstakeholders in stroke care (pp. 111–112).The new guidelines also recommend thatconsideration be given to transporting awitness, family member or caregiver whocan provide time-sensitive informationrelated to the patient’s events, thus expe-diting the patient’s care in the emergencydepartment.

With regard to stroke recognition, the

new guidelines stress the importance ofEMS personnel knowledge of the signs andsymptoms of stroke. Further, if stroke issuspected, all EMS personnel should becompetent in the utilization of a prehospitalstroke assessment tool (see Table 1, p. 27).

Finally, the new recommendations high-light the need for identifying the time ofonset of the patient’s symptoms. If possible,EMS personnel should also attempt to iden-tify the last time the patient was known tobe acting normally. This time does notalways correspond with the identified timeof symptom onset, but it has importantimplications with regard to available med-ical therapies.

ADVANCED CARDIAC LIFESUPPORTPulseless arrest algorithm (VF/pulselessVT; asystole/PEA): Individual algorithmsfor ventricular fibrillation, pulseless VT,asystole and PEA are now combined intoone algorithm—The Pulseless ArrestAlgorithm (see Figure 2, p. 16). This com-bination was designed to simplify clinicalapplication and to emphasize the key role ofhigh-quality CPR as an essential componentin all pulseless arrest resuscitations.

The most critical interventions duringthe first minutes of a VF/pulseless VT arrest


Figure 4: Asystole & Pulseless Electrical Activity—Treatment Sequences for ACLS & PALSSource: Currents. 16(4): 2005.


are immediate bystander CPR and defibril-lation. In cases of a witnessed arrest with adefibrillator on site, it should be appliedand used after you give two breaths anddetermine that a pulse is absent. New is theone-shock protocol, discussed above (seeFigure 3, p. 18). If VF/pulseless VT persists,give a vasopressor. Epinephrine 1.0 mg isstill recommended at three- to five-minuteintervals. Vasopressin 40U IV/IO can besubstituted for the first or second dose ofepinephrine. If adequate personnel areavailable, they need to anticipate theadministration of a vasopressor or anantiarrhythmia agent. Prepare the drug inadvance and administer it without interrupt-ing chest compressions. When VF/pulselessVT persists despite shocks and a vasopres-sor, consider an antiarrhythmic agent.Amiodarone is preferred but lidocaine maybe used if amiodarone is not available.

Asystole and PEA are ominous rhythmswith a poor survival rate. Because of thesimilarity in management, they are com-bined in the pulseless arrest algorithm.Again, high-quality CPR and effective chestcompressions are key to survival and inter-ventions are organized around the two-minute periods of CPR (see Figure 4, p. 19).The 2005 Guidelines emphasize early iden-

tification of a reversible cause, if possible,and an attempt at correction, as a bridge toa perfusing rhythm and definitive care.Administration of a vasopressor (either epi-nephrine or vasopressin) and atropine (forpatients in asystole or slow PEA) isunchanged.

Management of symptomatic brady-cardia & tachycardia: The tachycardiaalgorithms are simplified and incorporatedinto a single algorithm, Tachycardia withPulses (see Figure 6, p. 22). Both theTachycardia with Pulses algorithm and theBradycardia algorithm (see Figure 5,above) differentiate treatment based on thepresence of symptoms due to the rhythmabnormality.

If the patient has a tachycardia with apulse but is persistently symptomatic (usuallywith a heart rate ≥ 150 beats per minute)perform immediate synchronized car-dioversion. Symptomatic or unstable signsinclude altered mental status, ongoing chestpain, hypotension or other signs of shock.An IV may be established and sedationgiven if that will not delay the delivery ofsynchronized cardioversion. If the patient isstable, establish IV access and obtain a 12-lead ECG. Determine if the QRS is narrow(< 0.12 seconds) or wide (≥ 0.12 seconds).

If a narrow regular QRS complex is pres-ent, attempt vagal maneuvers. If vagalmaneuvers fail and EMS protocols author-ize, give adenosine, 6 mg rapid IV push. Ifno conversion, 12 mg rapid IV push may begiven and repeated once. That is unchangedfrom the 2000 Guidelines recommenda-tions. For EMS providers, additional man-agement is simplified. If conversion withvagal maneuvers fails or a regular or irreg-ular wide QRS complex is present seekexpert consultation. Be prepared to defibril-late or perform synchronized cardioversionif the patient or rhythm becomes unstable.

ALS ACS management: ALS providersmay need to begin or complete the initialassessment and management of a patientwith potential ACS (see BLS sectionabove). Initial EMS care includes theadministration of oxygen, aspirin andnitrates. If three doses of nitroglycerin havenot completely relieved chest discomfort,ALS personnel should consider administra-tion of morphine sulfate, if protocols permit(pp. 97–98).

ST-segment elevation myocardial infarc-tion, or STEMI, is usually due to a completeocclusion of a major coronary artery on thesurface of the heart. Heart muscle begins todie at about 15–20 minutes after interruptionof blood supply. Additional ACLS interven-tions, then, are directed toward a goal thatpermits rapid opening of this infarct relatedartery (IRA). Reestablishment of flow (reper-fusion) is critical in reducing death, decreas-ing heart failure and the complications ofmyocardial infarction. EMS interventionsshown to improve the likelihood of achievingearly reperfusion are (pp. 89–91):

• Out-of-hospital 12-lead-ECGs.• Prior notification of the receiving

facility.• Transport of the patient to an

appropriate facility.Performance of a 12-lead ECG, com-

pletion of a fibrinolytic checklist—whenappropriate—and advance notification ofthe receiving facility can speed the diagno-sis and shorten the time to reperfusion, andmay be associated with reduced infarctionand mortality. For these reasons, the 2005Guidelines recommend that qualified andspecially trained paramedics and pre-hospital nurses in urban and suburbanEMS systems complete these proceduresfor patients with a potential ACS (p. 91).

In general, diversion to hospitals withspecific reperfusion capabilities should beguided by local EMS protocols and is dis-

Figure 5: Bradycardia AlgorithmSource: Circulation. 112(24, Supplement): Dec. 13, 2005.


cussed in the EMS administrators section.When such protocols are in place, a specialsituation applies to patients in cardiogenicshock or with large myocardial infarctionand heart failure (impending shock). Signsof significant heart impairment that shouldbe recognized by EMS personnel are: 1) shock (usually defined as a systolic BP <80 mmHg), 2) heart rate > 100 bpm andblood pressure < 100 mmHg, and 3) pul-monary congestion (rales).

If any one or more of these signs arepresent, patients are at the highest risk fordeath and complications of STEMI. Thesepatients benefit from direct percutaneouscoronary intervention (PCI), for example,initial angioplasty/stent or surgical revascu-larization. When possible, such patientsshould be taken directly to an interven-tional facility. Also, patients who are not eli-gible for fibrinolytic therapy (see Figure 7,p. 23) should be taken to a PCI facilitywhen possible. Otherwise, a transfer will berequired. Recommendations related to thattransfer are discussed in the EMS adminis-trators section (p. 92).

ALS stroke management: The newstroke guidelines for ALS providers arelargely the same as those described for theBLS provider. Triage policies should beestablished that reflect the agreement ofregional stakeholders on stroke care.Competence in the use of a prehospitalstroke assessment tool remains a top pri-ority as is an appreciation for the impor-tance of identifying the last time a patientwas known to be acting normally. In addi-tion to the BLS level of care, ALS personnelshould always perform serum blood glu-cose measurements in accordance withtheir protocols. The need to identify hypo-glycemic patients manifesting abnormalneurologic function/behavior cannot beunderstated. Lastly, as with BLS, pre-hospital notification to the receiving hos-pital will allow medical resources to be pre-pared and mobilized promptly upon patientarrival (pp. 111–115).

PEDIATRIC PATIENTSCompression-ventilation ratio (see Figure8, p. 24): To simplify education and improveretention of the steps of CPR, a universal 30:2compression:ventilation ratio is recommend-ed for all single rescuers (lay and health-careproviders) and for all victims (except new-borns). In infants and children, however, theetiology of cardiac arrest is more often sec-ondary to hypoxia, hypercapnia or both

(called asphyxial arrest) rather than suddencardiac arrest from VF or pulseless VT. Thus,the use of a 30:2 compression:ventilationratio may not provide adequate ventilationto correct hypercarbia and hypoxemia.Therefore, a compression:ventilation ratioof 15:2 is recommended when two or morehealth-care providers are performing CPRtogether, which is the most likely scenario forEMS personnel. To simplify education andimprove retention for lay rescuers, they aretaught neither two-rescuer CPR nor the 15:2ratio for children and infants (see the layprovider section, below) (pp. 160–161).

Note that two-rescuer CPR is continuedfor approximately two minutes (about 10cycles of 15:2 CPR) in infants and childrenprior to defibrillation for unwitnessed out-of-hospital, the most likely scenario thatwould be encountered by EMS personnel.

Chest compressions for children (age 1 topuberty) may be performed with either oneor two hands, depending on the size of thepatient and the strength of the rescuer, withthe hands centered on a line drawn betweenthe patient’s nipples (intermammary line).Since it is important to achieve effectivechest compression and since fatigue is morelikely to occur with the use of only one arm,it is acceptable to use two hands providedthat the health-care provider does not applytoo much force (compression depth shouldbe one-third to one-half the depth of thechest) and does not compress over thexiphoid or on the ribs (pp. 160–161).

Chest compression in infants can be per-formed using two fingers, placed just belowthe intermammary line, rather than cen-tered over the intermammary line. Whentwo health-care providers are working


Stroke patients who require hospitalization should be admitted to a facility with a dedicated stroke unit (staffed by a multidisciplinary team experienced in managing stroke) when one is available within a reasonable transport interval.

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together, though, chest compressions canbe provided to an infant using the twothumb-encircling hands technique. Asnoted above, there is new attention to appli-cation of a thoracic squeeze with the fingersin addition to sternal compression with thethumbs (pp. 160–161).

Airway & ventilation: If cervical traumais not suspected, a head tilt-chin lift isrecommended to open the airway. If themechanism of injury suggests the presence

of cervical injury, the airway should beopened with a jaw thrust. If the latter is noteffective, then head tilt-chin lift may beapplied. Move the head only as far as isneeded to open the airway (pp. 157–158).

Note that providers are encouraged tomake a few attempts to open the airway inchildren and infants, as opposed to theinstructions for adults that place less empha-sis on ensuring effective ventilation with eachrescue breath (see CPR section, above). The

recommendations reflect the relativelygreater incidence of hypoxic arrest amonginfants and children (pp. 158–159).

In the pediatric patient with a perfusingrhythm who requires ventilation, providerescue breaths at 12–20 breaths/min (onebreath every three to five seconds), usingthe higher end of that range for infants andsmall children. Again, breaths should bedelivered over one second and the tidal vol-ume that is delivered should be sufficient to

Figure 6: Tachycardia AlgorithmSource: Circulation. 112(24, Supplement): Dec. 13, 2005.


just cause chest rise. The mnemonic,“squeeze-release-release” stated slowlyusing one second per word may be helpfulto deliver about 20 breaths/minute (p. 159).

For short transport times, bag-mask ven-tilation is preferred over attempts at endo-tracheal intubation for most EMS providers.In select situations, such as when transporttime is long, endotracheal intubation maybe used by trained health-care providers. Itis highly recommended that these providersparticipate in ongoing quality control toensure that endotracheal intubation is per-formed safely (pp. 168–169).

Following endotracheal intubation, tubeposition is confirmed by clinical exam-ination, as previously detailed, combinedwith detection of exhaled CO2, recognizingthat cardiac arrest victims may not havesufficient exhaled CO2 to be detected.When tube position is uncertain, it shouldbe confirmed by direct visualization of thetube passing through the glottic opening.An esophageal detector device is an accept-able alternative for children > 20 kg whohave a perfusing rhythm; there is no objec-tive data on the use of this device in cardiac

arrest victims (p. 169).If the health-care provider is properly

trained, an LMA may be used in place of endotracheal intubation. Similarly, apharyngeal-tracheal CombiTube may beused in children > 35 kg (p. 167).

As in adults, once an advanced airway isinserted in children, chest compressions aredelivered continuously at a rate of100/minute while ventilations are given at arate of eight to 10 breaths/minute (onebreath every six to eight seconds) withoutpausing chest compressions (p. 159).

Because pediatric cardiac arrests aremost commonly due to respiratory dis-orders, a higher than expected airway pres-sure is sometimes needed to achieve chestrise. For this reason, it is often more effec-tive for two or more rescuers to focus ondelivering the rescue breaths: one rescueropens the airway and seals the mask to theface while a second rescuer compresses theventilation bag. If a third rescuer is avail-able, he or she should apply cricoid pres-sure to reduce the risk of gastric distension(p. 168).

If permitted by your EMS agency, pas-

sage of an oro- or nasogastric tube is oftenhelpful after endotracheal intubation torelieve gastric distension that often compli-cates bag-mask or mouth-to-mouth venti-lation. Relief of gastric distension often sig-nificantly improves the effectiveness ofventilation (p. 168).

Drugs & drug administration (seeFigure 9, p. 26): In children who do notrespond to effective ventilation and chestcompression, administration of epinephrineis recommended. Vascular access is oftendifficult to achieve in children, so earlyinsertion of an intraosseous (IO) needle isrecommended and may be used in any agechild (p. 170) If vascular access cannot berapidly achieved, epinephrine may beadministered by the endotracheal routeusing a high dose (0.1 mg/kg) since stan-dard doses given by this route may causeperipheral vasodilation, reducing coronaryperfusion pressure (pp. 170, 172).

High-dose epinephrine is no longerroutinely recommended in children whofail to have ROSC with standard doses,because data show that it does notimprove survival and indeed may have an


Yes No

Yes No

Step Two:

Systolic BP greater than 180 mmHg ❏ Yes NoDiastolic BP greater than 110 mmHg ❏ Yes NoRight vs. left arm systolic BP difference greater than 15 mmHg ❏ Yes NoHistory of structural central nervous system disease ❏ Yes NoSignificant closed head/facial trauma within the previous 3 months ❏ Yes NoRecent (within 6 weeks) major trauma, surgery (including laser eye surgery), GI/GU bleed ❏ Yes NoBleeding or clotting problem or on blood thinners ❏ Yes NoCPR greater than 10 minutes ❏ Yes NoPregnant female ❏ Yes NoSerious systemic disease (e.g., advanced/terminal cancer, severe liver or kidney disease) ❏ Yes No

Step Three:

Heart rate greater than or equal to 100 bpm AND systolic BP less than 100 mmHg ❏ Yes NoPulmonary edema (rales) ❏ Yes NoSigns of shock (cool, clammy) ❏ Yes NoContraindications to fibrinolytic therapy ❏ Yes No

Adapted from: Circulation. 112(24, Supplement):IV-92, Dec. 13, 2005.

Figure 7: Chest Pain Checklist for STEMI Fibrinolytic Therapy

Has patient experienced chest discomfort for greater than 15 minutes and less than 12 hours?

Does ECG show STEMI or new or presumably new LBBB?

Step One:

Are there any contraindications to fibrinolysis?If ANY of the Following is CHECKED YES, Fibrinolysis MAY Be Contraindicated.

Is patient at high risk?If ANY of the Following is CHECKED YES, CONSIDER Transport/Transfer to PCI Facility.


adverse effect on patient outcome.4 In thechild who fails to have ROSC, emphasisshould be placed on ensuring that high-quality chest compressions are deliveredwith minimal interruptions and thatexcessive ventilation is avoided.

Although data are lacking comparingamiodarone with lidocaine in childrenwith life-threatening ventricular arrhyth-mias, based on adult data, amiodarone isconsidered the drug of choice in children.Lidocaine is an acceptable alternativewhen amiodarone is not available (pp.171–172).

EMS DISPATCHERS &SYSTEM ADMINISTRATORSEMS dispatcher training and protocols: The2005 Guidelines emphasize the integral roleof the EMS dispatcher. One of the mostvaluable functions of the EMS dispatcherwith respect to emergency cardiovascularcare is the provision of prearrival instruc-tions. EMS dispatchers have proven suc-cessful in this task for many years. Simplyproviding telephone CPR instructions hasproven to increase the likelihood ofbystander CPR being performed. Currentlyavailable medical dispatch programs have

recently been updated to accommodate dif-ferences in CPR instructions based on theetiology of the arrest. In specific cases (e.g.,poisoning, severe trauma, drowning), venti-lation should have a higher priority than itmight in cases of witnessed sudden cardiacarrest. Also key in determining appropriateprearrival instructions is the differentiationbetween normal breathing and agonalgasps. The presence of agonal gasps maycause the caller to believe the victim isbreathing effectively. Dispatchers shouldask if the victim is “breathing normally.” Ifthe caller is unsure whether the victim isbreathing normally (or breathing at all),dispatchers should assume that there is nonormal breathing present in the adult car-diac arrest victim. Remember, there is farless potential to do harm from advising thecaller to perform CPR when it’s not reallynecessary than there is from advising thecaller not to do CPR when, in fact, it isneeded by the victim (p. 20).

Medical dispatch programs should beupdated to ensure that the 2005 Guidelinesare reflected in dispatchers’ questions.System administrators responsible forupdating medical dispatch programs mustcritically evaluate their existing programsand provide retraining, as needed.

The 2005 Guidelines address one addi-tional and often overlooked component—quality improvement (QI). EMS dispatchadministrators should implement a QI pro-gram that evaluates, retrospectively, theactual use of the dispatcher scripts andwhether the questions asked led to the mostappropriate instructions (p. 29).

CPR first: The 2005 Guidelines reaffirmthe value of early, high-quality CPR.Perhaps just as important to the EMSprovider are the recommendations relatedto the integration of CPR with defibrillation:“one-shock protocol” and “CPR first” (forunwitnessed arrest), both discussed above.Of the two recommendations, implementa-tion of the latter could be more complex,particularly if it is linked to the length ofthe response time (9-1-1 call-to-arrivalinterval). With that approach, responderswould need to be aware of their responsetime to know whether they should provideCPR for two minutes before attemptingdefibrillation or for only as long as it takesto get the defibrillator ready. On the otherhand, a medical director may wish to imple-ment CPR-first as the default action for alladult victims who are in arrest prior to EMSarrival. This is the case in several U.S. met-

Figure 8: Pediatric Health-Care Provider BLS Algorithm (Note: The boxes borderedby dotted lines are performed by health-care providers and not by lay rescuers.)Source: Circulation. 112(24, Supplement): Dec. 13, 2005.


ropolitan areas today. That is why this CPR-first protocol was worded in a “permissive”way for EMS personnel (“may give …”)rather than in a prescriptive way (“shouldgive …”) and is recommended for consid-eration by EMS administrators.

If an EMS system decides to adopt aCPR-first protocol, changes in written pro-tocols and training are required. If the prac-tice is contingent upon response time, amechanism for tracking that will also berequired (portable radios would make thispretty easy to accomplish). Appropriateprotocols and training scenarios should becreated so that trainees learn to assess thevictim and immediately begin CPR, eventhough a defibrillator is present (unlessprotocols for known, short response timesare also implemented). The scenarios usedin this training must illustrate that CPRshould continue for at least two minutesprior to rhythm assessment and shock(“CPR first”). Instructors should also uti-lize scenarios that illustrate performingCPR for only as long as it takes for a secondrescuer to prepare for rhythm assessmentand shock (“immediate defibrillation”)when the responder witnesses the cardiacarrest (or if a protocol for known, shortresponse times is also implemented).

Prehospital ECG: The 2005 Guidelinesreaffirmed the importance of early identi-fication and treatment of ACS, particularlySTEMI. In fact, implementation of pre-hospital 12-lead ECG diagnostic programsin urban and suburban EMS systems wasassigned the highest class of recom-mendation. This presents no small chal-lenge for many EMS administrators. Thetechnology and training to acquire, trans-mit and/or interpret the 12-lead ECG sim-ply does not exist in many systems. It is,however, an appropriate goal for EMS sys-tems in all settings and has been shown tointroduce a minimal increase (0.2 to 5.6minutes) in the on-scene time interval.The potential benefits of prehospital ECGinterpretation are clear. Studies haveshown that the reduction in the timerequired to deliver reperfusion therapy tothe patients after arrival at the hospital(the door-to-reperfusion interval) can rangefrom 10–60 minutes when prehospitalECG programs are in place (p. 91).

To achieve the greatest effectiveness,EMS responders must be trained to inte-grate ECG evaluation of every suspectedACS patient into the patient’s overall care(as described in a previous section). Once


Crews must continue chest compressions while their defibrillator is chargingand immediately resume compressions after a shock without a pulse or rhythmcheck for five cycles of CPR (about two minutes) before assessing the rhythm again.

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the 12-lead ECG is acquired, the EMSresponder should either communicate theECG interpretation (if trained to do so) ortransmit the ECG to the receiving facilityfor interpretation. Receiving hospitalsshould, in turn, use the 12-lead ECG inter-pretation to prepare for the suspected ACSpatient. If EMS providers identify STEMI onthe ECG, it is reasonable for them to initi-ate a fibrinolytic checklist (p. 91).

EMS systems that routinely acquire and

transmit and/or interpret the 12-lead ECGshould implement a continuous QI pro-gram aimed at reducing the overall time toreperfusion. Accurate ECG interpretationand early notification of the receiving facil-ities should be the focus of such efforts. Forsystems that already have 12-lead ECGacquisition capability, the impact of thisguideline is limited to a focus on qualityimprovement efforts.

Out-of-hospital administration of

fibrinolytics: As discussed previously, early12-lead ECG acquisition and interpretationremains a primary focus of prehospital carefor suspected ACS. Some EMS systems may,however, choose to also implement out-of-hospital delivery of fibrinolytic agents.While the 2005 Guidelines affirm the safetyand feasibility of this intervention, EMS sys-tems must be prepared for the additionalchallenges posed by prehospital administra-tion of fibrinolytics to the STEMI patient.

Figure 9: PALS Pulseless Arrest AlgorithmSource: Circulation. 112(24, Supplement): Dec. 13, 2005.


One critical challenge for the paramedicadministering fibrinolytics in the out-of-hospital setting is performing an effectiveassessment for contraindications to fibri-nolysis. The EMS system, particularly theEMS medical director, must develop aprocess for fibrinolytic administration thatis focused on identifying the right patient,at the right time and under the right cir-cumstances. A checklist used to determinethe eligibility of the patient and a checklistto guide the administration procedure canminimize error and improve patient safety.

Another critical element of such aprocess is paramedic skill in the rapid acqui-sition of a quality 12-lead ECG and therapid, accurate interpretation of the 12-leadECG. Electronic transmission of the 12-leadECG to a qualified physician serves as aneffective consulting resource to the para-medic. The ability to communicate (voiceand ECG data) with the receiving facilityremains another critical element for thoseEMS systems administering fibrinolytics.

Even more important to the success of anout-of-hospital fibrinolysis program is theactive involvement of a medical directorexperienced in the management of STEMIpatients. The medical director must work toensure safety and efficacy of this programby regularly measuring the effectiveness ofthe program and implementing improve-ments as needed. It is worth repeating thatthe Guidelines place more emphasis on theimportance of EMS systems focusing on 12-lead ECG acquisition, transmission and/orinterpretation along with early notificationof the receiving facility than on providingprehospital fibrinolytic therapy (p. 91).

Out-of-hospital triage of suspected orconfirmed STEMI: For several years, EMSsystems have grappled with the issue oftransport protocols for suspected or con-firmed STEMI patients. Inadequate evi-dence was available to make specific recom-mendations about triage and bypass ofpatients directly to a PCI capable facilitybased on the available evidence. In addi-tion, the Guidelines could not effectivelyaddress all of the EMS system issues associ-ated with triage and bypass. Therefore, theEMS system and its medical director musttake responsibility for program design atthe local level. In doing so, transport time,system resources, the availability of PCI-capable facilities along with local hospitalmedical management capabilities must beconsidered, keeping in mind that “bypass”orders will have an impact on hospital sys-

tem resource allocation, particularly in therural EMS setting.

In addition, when STEMI patients withcontraindications to fibrinolytic therapyarrive at a facility that cannot perform PCI,transfer to another facility will be necessary.The 2005 Guidelines concur with theACC/AHA 2004 STEMI Guidelines by rec-ommending that patients who require suchinter-facility transfer depart from the initialhospital within 30 minutes after their arrival(door-to-departure time of 30 minutes). Thiswill require coordination and integration ofED and EMS system protocols (p. 92).

Direct transport to a dedicated strokeunit: There is strong evidence to supportimproved outcomes of stroke patients whoare managed in stroke units. The benefit of stroke units appears to stem from thecoordinated, multidisciplinary care thatthese units offer. As a consequence, the newguidelines instruct EMS personnel to con-sider triaging stroke patients to hospitalsthat can provide this level of care.Recognizing that unique geographic, time,distance and resource variables complicatetriage decisions by EMS personnel, the needfor proactively developed triage guidelinesis self-evident. It is critical that all stake-holders in stroke care be involved in thisprocess so that the final policy can provideclear direction for EMS personnel at thetime of patient care (pp. 113–115).

Improving response intervals: EMS sys-tems throughout the U.S. have long grappledwith the issue of improving response times.In urban settings, increasing populations,traffic congestion and victim access com-

pound the problem of shortening responseintervals. In contrast, rural EMS systems arefaced with sparse populations, fewerresponse units, longer hospital transporttimes and fewer trained and available respon-ders. While adding response vehicles oftenseems to address the issue, increasingly limit-ed financial resources are making thisapproach less desirable. Shortening the EMSresponse interval (call to arrival time) isimportant, but the greatest impact on survivalis realized when the response interval isreduced to less than five to six minutes. EMSsystems should use a QI program to evaluatethe effectiveness of their response to cardiacarrest victims. Measuring the rate of survivalto hospital discharge for VF sudden cardiacarrest should be used to determine the effec-tiveness of any system changes (pp. 16, 19).

The 2005 Guidelines clearly emphasize theimportance of providing immediate, high-quality CPR with minimum interruptionsand early defibrillation. EMS system admin-istrators should consider how well thesetwo therapies (high-quality CPR and effec-tive defibrillation) are provided to victimsof sudden cardiac arrest. Administratorsshould not overlook or underestimate thevalue of fostering strong communityinvolvement in their efforts to improve sur-vival to hospital discharge. CommunityCPR training and AED programs, stronglytied to the EMS system, are a key element ofa community’s response system and mayprovide an economically reasonable ap-proach to augmenting EMS responses tocardiac arrest in settings where responsetimes are not optimal (pp. 12, 35, 37–38).


Table 1: The Cincinnati Prehospital Stroke Scale

Facial Droop (have patient show teeth or smile): ❑ Normal—both sides of face move equally ❑ Abnormal—one side of face does not move as well as the other side

Arm Drift (patient closes eyes and holds both arms straight out for 10seconds): ❑ Normal—both arms move the same or both arms do not move at all (other

findings, such as pronator drift, may be helpful) ❑ Abnormal—one arm does not move or one arm drifts down compared with

the other

Abnormal Speech (have the patient say, “You can’t teach an old dog newtricks.”): ❑ Normal—patient uses correct words with no slurring ❑ Abnormal—patient slurs words, uses the wrong words or is unable to speak

Interpretation: If any one of these three signs is abnormal, the probability of a stroke is 72%.

Adapted from: Circulation. 112(24, Supplement):IV-113, Dec. 13, 2005.


Improving CPR: The hemodynamicsgenerated by CPR and the resulting out-come are dependent on the quality of CPRdelivered to a victim of cardiac arrest. EMSsystems should focus on methods toimprove the quality of CPR provided byhealth-care providers. These may includeeducation, training, assistance or feedbackfrom biomedical devices, mechanical CPRand electronic monitoring. Components ofCPR known to affect hemodynamicsinclude ventilation rate and duration; com-pression depth, rate, and number; achievingcomplete chest recoil; and limiting hands-off time. Systems that deliver professionalCPR should implement processes of contin-uous QI that include monitoring the qualityof CPR delivered on scene at a cardiacarrest, other process-of-care measures (e.g.,initial rhythm, bystander CPR and responseintervals) and patient outcome to hospitaldischarge. This evidence should be used tomaximize the quality of CPR delivered. TheAmerican Heart Association and theInternational Liaison Committee onResuscitation have published recommend-ed data elements that should be acquired aspart of a comprehensive QI program.5

Those same elements have been integratedinto the National Emergency MedicalServices Information System (NEMSIS)dataset. Any patient care record system thatis NEMSIS compliant will provide an ade-quate complement of EMS data.

LAY PROVIDERSOne goal of the 2005 Guidelines is to furthersimplify CPR and first aid for lay providers,thus, increasing the chance that you’ll findsomeone aiding a victim when you arrive onscene. The 2005 Guidelines for lay providersare different in the following ways.

Assessment of the need for CPR: Layrescuers are no longer told to look for signsof circulation after giving two rescuebreaths. Once the lay rescuer has deter-mined that the victim is not breathing nor-mally and two rescue breaths have beendelivered, he or she will immediately beginchest compressions. This change is basedon the idea that the subsequent assessmentfor signs of life was largely based on a re-assessment of breathing (as well as lookingfor coughing or movement). This addedstep was, then, redundant with the initialassessment of breathing. Eliminating the

signs of life assessment for lay rescuersreduces the delay before delivery of chestcompressions to people who are in cardiacarrest and it eliminates a decision point thatcould lead to a lay rescuer deciding not todeliver chest compressions to someonewho, in fact, needs them (pp. 13–14).

The implication for you is that there willbe less likelihood of finding a bystanderdelivering just rescue breaths. It’s “all ornothing.” Lay provider courses based on the2005 Guidelines will teach rescue breathswith compressions, but not rescue breath-ing, alone.

Compressions: Lay rescuers are instruct-ed to perform CPR using a 30:2 compression:ventilation ratio on all victims. Unlikehealth-care providers, they are not taught toperform two-person CPR and, therefore, arenot taught to use the 15:2 ratio for childrenand infants. The target compression ratetaught to lay providers does not differ fromyour own training: 100/minute.

AED protocols: Lay rescuers, likehealth-care professionals, will be taught toprovide two minutes of CPR immediatelyafter each shock from a defibrillator (anAED, in the case of lay rescuers and basic

When two or more health-care providers are present during CPR, rescuers should administer medications without inter-rupting compressions. They should also rotate the compressor role every two minutes (see opposite).

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EMTs). That means that, unless a victimbegins breathing spontaneously (or beginsto breath normally and move voluntarily) atany time during the resuscitation attempt,lay rescuers will continue with cycles ofanalysis, shock (if advised) and two min-utes of CPR until an ALS team arrives. Soeven if an automatic rhythm analysis by theAED says that there is “no shock advised,”the lay rescuer will continue with CPR andallow the AED to reassess the victim aftertwo minutes. It will be up to you to deter-mine if a victim has had a return of sponta-neous circulation upon your arrival anddetermine if chest compressions should bediscontinued (p. 36).

For kids, call 9-1-1 after five cycles of30:2: As before, lay providers are advised toinitiate CPR for an unresponsive child whois not breathing, prior to calling 9-1-1. Now,the recommendation is to initiate and con-tinue that CPR for five cycles of 30:2, abouta minute longer than the old recommenda-tion. The impact of this is that 9-1-1 callsmay come in a little later in the arrest thanbefore implementation of this change. It ishoped, though, that the longer initial effortby the lay rescuer will result in a greater

probability of a successful resuscitation ofthe child victim (pp. 14, 157).

No jaw thrust used: Lay providers willno longer be taught to use a jaw thrust toopen the airway for victims suspected ofhaving a head or neck injury. It has beeneliminated from lay training because thereis a possibility of moving the neck whenusing that maneuver and because it is noteasy to teach or to perform. So, in theevent that you respond to a cardiac arrestthat is associated with head or neck trau-ma, lay providers will not have used a jawthrust, and the head will most likely havebeen moved from its original position (pp. 21, 157).

Epi pens & inhalers: Lay rescuers arenow advised to assist victims in using thevictims’ own epi-pens and asthma inhalers.In the past, this has not been advised.Perhaps this change will increase the likeli-hood that a patient will have received thesemedications prior to your arrival (p. 197).

CONCLUSIONThe 2005 CPR and ECC Guidelines includemany changes that have the potential tochange the way EMS is delivered throughout

the United States. Although this supplementhighlights most of the changes that will havea direct impact on EMS, EMS managers andsupervisors should review the Guidelines intheir entirety when determining whatchanges to implement in their systems.

REFERENCES1. Wik L, et al: “Quality of cardiopulmonary

resuscitation during out-of-hospital car-diac arrest.” JAMA. 293(3):299–304, 2005.

2. Weisfeldt M, Becker L: “Resuscitationafter cardiac arrest: A 3-phase time-sensitive model.” JAMA. 288(23):3035–3038, 2002.

3. Berg M, et al: “Post-shock chest compres-sion delays with automated external defib-rillator use.” Resuscitation. 64(3):287–291,March 2005.

4. Perondi M, et al: “A comparison of high-dose and standard-dose epinephrine inchildren with cardiac arrest.” New EnglandJournal of Medicine. 350:1722–1730, 2004.

5. Jacobs I, Nadkarni V, Bahr J, et al:“Cardiac arrest and cardiopulmonaryresuscitation outcome reports ... .”Circulation. 110(21):3385–3397, Nov. 23, 2004.

In this photo, the Seattle firefighter who was ventilating the patient (see opposite), changed positions with the firefighter giving compressions after two minutes. The switch occurred in less than five seconds with minimal interruption of chest compressions.



The new AHA guidelines for CPR and emer-gency cardiovascular care are based on anevaluation of 22,000 peer review journalarticles conducted by 281 scientists fromthe international resuscitation communityin preparation for the 2005 InternationalConsensus Conference on CPR and ECCScience with Treatment Recommendations.According to the AHA, the 2005 guidelinesare “based on the most extensive evidencereview of CPR ever published.”

This article examines how the newguidelines impact lay rescuer automatedexternal defibrillation (AED) programs incommunity settings outside the hospital,highlighting information that programdirectors of public access defibrillation(PAD) and other on-site AED programsneed to know.

LESSONS LEARNED FROMRECENT RESEARCHLessons learned about effective treatmentof SCA since publication of the last guide-lines in 2000 include the following keydevelopments:

• Lay rescuer AED programs in airportsand casinos and first responder AEDprograms with police officers haveresulted in survival rates of 41–74%from out-of-hospital witnessed SCA

when the patient is in a shockablerhythm (ventricular fibrillation orVF), immediate bystander CPR is pro-vided, and AEDs are used withinthree to five minutes of collapse. Inaddition, the Public AccessDefibrillation (PAD) trial, a largeprospective randomized clinical trialfunded by the National Heart, Lungand Blood Institute (NHLBI), theAHA and several AED manufacturers,found that lay rescuer CPR-AED pro-grams double the number of sur-vivors from out-of-hospital VF SCAwhen compared with programs thatprovided lay-rescuer CPR only.

• If SCA is witnessed, the best course ofaction is to treat the adult patientimmediately with a defibrillator.

• There is a high rate of first-shock suc-cess with modern defibrillators. Mostpatients whose arrests are witnessedand who are treated immediately withAEDs are converted out of VF follow-ing the first shock (80–90%).

• Even when the patient is successfullydefibrillated, a perfusing rhythm isnot normally present for several sec-onds or minutes. Therefore, rescuersshould resume CPR, starting withchest compressions immediately after

a shock is delivered.• If the first shock fails and the patient

remains in VF, it is most helpful toprovide CPR because chest compres-sions can improve the likelihood thatsubsequent shocks will be successful.

• The quality of CPR has a strong influ-ence on survival. It is important toprovide compressions at an effectiverate and depth, to completely releasepressure on the chest after each com-pression and to minimize interruptionsin compressions. It is also important toprovide effective ventilations and avoidover-ventilation.

SUPPORT FOR LAYRESCUER AED PROGRAMSThe 2005 guidelines changes representgood news for lay rescuer AED programs.For the first time ever, science solidly sup-ports the value of lay rescuer AED programsin certain locations. Further, the AHA hasrecognized that physician oversight of layrescuer AED programs is not essential—aslong as a qualified health-care provider,such as a nurse or paramedic, provides pro-gram oversight.

In addition, treatment protocols havebecome simpler and should be easier toremember. Following is a summary of keytreatment and programmatic guidelinechanges. (See Figure A for a list of nationalCPR/AED training organizations.)

TREATMENT CHANGESLay rescuers who encounter unresponsivevictims who are not breathing should pro-vide two breaths and then begin chest com-pressions. There is no need to assess othersigns of circulation. Rescue breaths shouldtake one second and should achieve visiblechest rise. One-rescuer CPR for all victims

Lay Rescuer AEDPrograms & the2005 Guidelines forECC & CPR By Mary Newman

Guideline (n): An official recommendation indicating how somethingshould be done or what sort of action should be taken in a particular circumstance. —Encarta World English Dictionary

Figure A: National CPR/AED Training Organizations

American Heart Association www.americanheart.org 877/AHA-4CPR

American Red Cross www.redcross.org/services/hss/ 800/RED-CROSS

American Safety & Health Institute www.ashinstitute.com 800/682-5067

Medic First Aid International www.medicfirstaid.us 800/800-7099

National Safety Council www.nsc.org 800/621-7619


Manufacturer Brands G5R Plans Contact Information

Cardiac Science First Save, Power Heart G3, Software upgrades available in 2006. www.cardiacscience.com;

Power Heart G3 Pro 800/426-0337

DefibTech Lifeline, Reviver Software upgrades for AEDs in field available this www.defibtech.com

spring. May be upgraded directly by end-user 866/333-4248

free of charge.

HeartSine Samaritan PAD, Actively working to comply with new AHA www.heartsine.com

Technologies Samaritan AED Guidelines. Release date has not been finalized. 866/HRT-SINE

Medtronic LIFEPAK CR Plus, LIFEPAK Free upgrades for all devices shipped after www.medtronic.com

EXPRESS, LIFEPAK 500, Nov. 28, 2005. Upgrades available for biphasic 800/442-1142

LIFEPAK 500 DPS defibrillators shipped before Nov. 28, 2005.

Pricing and availability to be announced.

Philips Medical Home/On-site, Forerunner: All units can be configured to be www.philips.com/heartstart

Systems FRx, FR2+, Forerunner G5R now. 800/722-7900

FR2+: Units presently shipping can be configured

to be G5R now.

Home/OnSite and FRx: All units can be configured

for Guidelines-compliant one-shock series and

two minutes of CPR now. Units will start shipping

in 2006 with CPR Coaching optimized for new

Guidelines and minimal CPR interruption. Units

already shipped may be updated in 2006 for

Guidelines-optimized CPR coaching via a program

designed to minimize customer effort and time

device is out of service.

Welch Allyn AED 10 All existing AED devices are upgradeable to www.welchallyn.com

new guidelines. Program outlining upgrade 800/462-0777

procedure and pricing to be announced in

Q1, 2006. New G5R AEDs will ship in Q1 2006.

ZOLL Medical Corp. AED Plus, AED Pro AED Plus will be G5R before October 2006 using www.zoll.com

upgrade kit with additional operating configurations 800/348-9011

to current product and adjustments to graphical

user interface. AED Plus covered by ZOLL’s

Guidelines 2005 Guarantee. Upgrade kits free of

charge to customers who purchased AED Plus

after Oct. 1, 2005. For other customers, nominal

fee will be charged.

AED Pro is G5R. ZOLL Guidelines 2005 Guarantee

applies to all versions of AED Pro. Configuration file

for upgrading previous versions to G5R available

from ZOLL at no cost. Modifications require

software changes only—no hardware or labeling

changes necessary.

Figure B: Making AEDs ‘Guidelines 2005 Ready’ (G5R)


(except newborn infants) should now beprovided at a ratio of 30 compressions totwo breaths. When any rescuer witnessesSCA and an AED is immediately availableon site, the rescuer should treat the victimwith the AED immediately. For treatmentof VF SCA, rescuers should provide oneshock with the defibrillator and immedi-ately resume CPR, starting with chest com-pressions. (Previously three stacked shockswere recommended.) Strong chest com-pressions are critical to resuscitation suc-cess. Rescuers should push hard and fast(at a rate of 100 compressions per minute),allow the chest to fully recoil between com-pressions and strive to minimize interrup-tions in compressions.

“For the lay rescuer who witnesses anSCA, the treatment is the same—retrievethe AED and administer a shock immedi-ately if indicated,” says Roger D. White,MD, of the Mayo Clinic, SpecialContributor to the 2005 Guidelines andmember of the AHA ACLS Committee.“What is different is resumption of chestcompressions immediately after the firstshock is delivered. If the first shock doesn’twork, then the patient likely will benefitfrom CPR.”

“While it is true that there are circum-stances in which an expanding body of evi-dence indicates that CPR preceding the firstdefibrillation shock might be advantageousin terms of shock success and patient out-come, this circumstance almost never pre-vails in settings in which lay rescuers arelikely to use an AED,” said White. “Rather,it is applicable to EMS responders, forwhom the time to reach the victim is typi-cally considerably longer. Thus, for lay res-cuers a shock-first policy, followed by CPR,is the optimal sequence.”

Another change is recognition that somepatients will benefit most from a shock first,while others will benefit most from CPRfirst. For EMS providers, one of the most

challenging aspects about the decision toshock first or provide CPR first is when todo which intervention first. This is why werecommend that unless the event is wit-nessed or the rescuer is using a smart defib-rillator that indicates otherwise, the rescuershould provide CPR first. When theresponse time exceeds five minutes, there isevidence that CPR first may be beneficial.Evolving and already available ECG analy-sis technology will enable devices to deter-mine whether the patient needs CPR orshocks first.

PROGRAM CHANGESLay rescuer AED programs in places whereSCA is likely to occur are now considered aClass I recommendation. These locationsinclude sites similar to those in the PADtrial (i.e., sites with a history of at least oneSCA every two years or sites that have morethan 250 adults over 50 years of age presentfor more than 16 hours a day). For instance,the AHA supports placement of AEDs intargeted public areas, such as airports, jails,casinos, sports arenas, gated communities,office complexes, doctor’s offices and shop-ping malls. Qualified health-care providersmay provide oversight of lay rescuer AEDprograms. Previously, physician oversightwas recommended.

“This is the first time that AHA guide-lines have designated PAD programs inplaces SCA is likely to occur a Class I rec-ommendation,” says Mary Fran Hazinski,RN, clinical nurse specialist fromVanderbilt University and Senior ScienceEditor of the 2005 Guidelines. This doesnot mean merely AED placement, Hazinskinoted, citing some cases in which AEDswere available but left unused, and othersin which AEDs were used but rescuers didnot know how to perform CPR whenprompted by the devices. “There is a differ-ence between AEDs and AED programs,”Hazinski emphasizes.

ACTION CHECKLIST FOREFFECTIVE LAY RESCUERAED PROGRAMSWhat do you need to do to make your layrescuer AED program as effective as possi-ble? According to the new guidelines, atten-tion to the following elements will help:

• Identify a qualified health-careprovider to provide program oversight.

• Develop, practice, and follow a written response plan.

• Identify and train likely rescuers, taking into account the need forrefresher training and rescuerturnover. Remember that SCA victims may need CPR, treatmentwith an AED or both, so rescuersshould be prepared to not only to use the AED but also to provide quality CPR.

• Be sure the program is integrated with the local EMS system.

• Develop and implement a process ofongoing quality improvement thatfeature routine inspections of AEDdevices and electrodes, and evaluationof post-event data including responseplan effectiveness, rescuer perform-ance, and AED function.

THE BOTTOM LINEWho shall live? Who shall die? The answerlies in the speed with which the SCA victimreceives effective treatment. The most effec-tive treatment is that which arrives withinminutes of collapse. It does not matter whoprovides CPR, as long as it is providedquickly and effectively. It does not matterwho carries the AED as long as it is usedquickly and effectively. The type of AEDused is less important than the speed withwhich it is used. And yes, the quality ofCPR matters.

In the end, the most important determi-nant of survival from SCA is the presenceof trained rescuers who are ready, willingand able to intervene effectively.Communities that want to make a differ-ence should work to increase awarenessabout SCA as a leading cause of death,train their citizens in CPR and AED use,and make AEDs readily available in high-risk settings. When the vital role ofbystander acumen, action, and access tolifesaving equipment is fully recognized,survival from SCA will become the rule,rather than the exception.

A compression:ventilation ratio of 30:2 has been recommended for all rescuers

(lay or health-care provider) who are actingalone in a resuscitation attempt of victims

of all ages (except for newly born).


Q: What is the rationale for the changefrom a 15:2 compression:ventilationratio to a 30:2 ratio, and has anyonestudied the effects of this change onrescuer fatigue?A: Although no studies have specificallycompared the effectiveness of the 30:2compression:ventilation ratio with the 15:2ratio on survival or differences in rescuerfatigue, a growing body of research indi-cates that interruptions in compressionscan have a detrimental effect on outcome.In fact, research shows that in real-worldscenarios using the 15:2 ratio, compres-sions are provided only half the time. A newstudy, for example, indicates that when layrescuers interrupt compressions to providebreaths, they typically stop compressionsfor 15 seconds. This means circulation ceasesand the rescue effort retreats to baseline.

“We believe that providing more compres-sions and fewer breaths will provide a bettermatch for patient needs than previous proto-cols,” says Michael Sayre, MD, emergencyphysician from The Ohio State Universityand chair of the AHA BLS Committee andpresident of the SCA Network.

Although rescuer fatigue also affects out-come, it is better for the patient if the res-cuer continues fast, forceful chest compres-sions (“push hard, push fast”) than to pausetoo often for ventilations, pulse checks orrhythm assessment. This is because provid-ing ventilations at a “normal” rate is lessimportant than previously realized, andpulse checks are unreliable at best, evenwhen performed by highly skilled health-care providers. To compensate for rescuerfatigue, experts recommend switching res-cuers every two minutes, if possible.

“There are no data to indicate that the30:2 ratio is more or less tiring than the15:2 ratio. It is probable that rescuers willtire more quickly with the new ratio, but if

this is better for the patient, then it is adesirable goal,” according to Sayre. “If a sec-ond rescuer is available, then switchingevery two minutes will likely be helpful. Ifthe rescuer is alone, there is no good way toget around the challenge of rescuer fatigue.”

An additional benefit of selecting the 30:2ratio as a universal protocol for all patients(except newborns) is that it is expected toimprove learning and retention and makeapplication in real life more realistic.

Q. Do the new guidelines mean thereis renewed emphasis on CPR anddefibrillation is less important?A. Yes—and no. Although there is arenewed emphasis on CPR, defibrillation isstill essential. Decades of research have sup-ported the importance of CPR and recentstudies continue to validate its importance.The quality of CPR matters and patientswill benefit from fast, forceful chest com-pressions delivered with minimal interrup-tions. At the same time, defibrillation is stillcritically important, especially in the firstfew minutes after collapse.

“I share the concern,” says White, “thatwhenever we try to prioritize a particularmaneuver, other maneuvers will be misun-derstood as less important. Fortunately,because of the effectiveness of modernAEDs, in cases of witnessed VF in which theAED is used immediately, resumption ofchest compressions after the initial shockshould expedite rapid restoration of sus-tained spontaneous circulation.”

Q. What about the use of AEDs totreat children?A. Although VF is relatively uncommon inchildren, it does occur in 5–15% of pedi-atric SCA cases. In these cases, rapid defib-rillation can improve outcomes. For chil-dren ages one to eight, a pediatric dose of

electrical therapy should be used if possi-ble. Some AEDs adjust the dosage throughpediatric dose-attenuator systems; othersuse different methods to adjust to a pedi-atric dose. If a child is in VF and a devicewith pediatric capabilities is not available, astandard AED should be used.

The guidelines do not recommend for oragainst AED programs in locations withchildren routinely present, such as schools,but they do recommend that AED programsestablished in such locations should installAEDs capable of administering pediatricdoses.

Scientific evidence is insufficient to rec-ommend for or against use of AEDs in chil-dren under age one.

Q: We plan to start a new on-site AEDprogram at our health club. Should wewait until training courses have imple-mented the new guidelines?A. No. In the meantime, you could lose anopportunity to save a life. Previous AHAguidelines and courses based on thoseguidelines have helped save many lives. Ifyou do not already have an on-site AEDprogram and your location is considered arelatively high-risk site for an SCA event, donot hesitate to get started.

Frequently AskedQuestionsWhat do these changes mean for directors of lay rescuer AED programs? Following are answers to some frequently asked questions. Feel free to copy this page and distribute to program directors in your area.

HeartStart FRxwith pediatricpads

Lay Rescuer AED Programs | By Mary Newman, [email protected]

AED Plus w

ith

child se

ttings


You can update potential rescuers oncenew courses become available. All national-ly recognized CPR-AED training programsexpect program materials to be updated bythe spring or early summer of 2006.

“These new guidelines do not imply thatcare based on earlier guidelines is eitherunsafe or ineffective, including the use ofAEDs that conform to those earlier guide-lines,” according to Jerry Potts, PhD, direc-tor of science, AHA ECC Programs. “Forthis reason and because of the criticalimportance of providing immediate care toa victim of sudden cardiac arrest, the AHAencourages implementation of (and train-ing for) lifesaving medical emergencyresponse plans (including AED programs)to continue without interruption or consid-eration of the pending publication ofrevised training materials.”

“The old guidelines are still good,” saysSayre. “They definitely resulted in savinglives. The main difference is that the newguidelines will make resuscitation easier tolearn and easier to accomplish.”

“Nothing needs to be on hold,” addsHazinski.

Q: We just implemented a corporate-wide AED program that involved train-ing of an extensive network of poten-tial rescuers. Do we need to updatetraining for everyone immediately orcan this be done gradually?A. The new guidelines reflect the latest inresuscitation science and offer what is con-sidered by experts to provide the best-known care for SCA victims. It is reasonableand defensible for entities with AED pro-grams to gradually phase in the new guide-lines. If your corporation develops andimplements a policy to gradually train

potential rescuers according to the newguidelines over a period of two years, forexample, this is a reasonable and prudentcourse to follow.

“We hope that EMS systems and PAD pro-grams will implement the new guidelines asquickly as they can because we believe thiswill improve survival. The old way works,but the new way can work even better,” saysSayre. “However, we know people need newtraining materials and we know that pro-grammatic changes take time.”

Q: Do we need to be concerned aboutliability risks if it takes our organiza-tion some time to fully implement thenew guidelines? A. According to the AHA guidelines pub-lished in Circulation, “These new recom-mendations do not imply that care involv-ing the use of earlier guidelines is unsafe.In addition, it is important to note thatthese guidelines will not apply to all res-cuers and all victims in all situations. Theleader of a resuscitation attempt may needto adapt application of the guidelines tounique circumstances.”

Richard A. Lazar, Esq., CEO of AEDRisk Insights, publisher of the AED LawCenter and member of the SCA NetworkBoard of Directors, says that regardless ofthe way the new guidelines are ultimatelyviewed by the legal and public policy com-munities, immediate implementation isnot possible. “You can’t expect thesechanges to occur overnight,” says Lazar.“According to market estimates (Frost &Sullivan, 2005), there are approximately300,000 AEDs in public settings in theU.S. In addition, there are probably mil-lions of trained rescuers nationwide whomay need to be retrained. It’s fair to say it

will take time to update so many devicesand rescuers. In my view, at least two yearsis a reasonable transition period. It cer-tainly is unreasonable to expect the mar-ket to move more quickly.”

Q: When can we expect AED compa-nies to update their software to reflectthe new guidelines?A. All AED companies are working to updatetheir software to reflect the new guidelinesand make them “Guidelines 2005 Ready” orG5R. Some models can be reconfigured with-out software modifications. Others requireinstalling software updates. Changes willinclude adapting to the one-shock protocoland adding verbal prompts to resume chestcompressions. For device specific informa-tion, see Figure B (p. 31).

Q. Do the new guidelines indicatewhich defibrillator waveform is supe-rior for patient outcome?A. Defibrillators on the market includemonophasic waveform defibrillators andboth fixed and escalating biphasic wave-form defibrillators. According to the guide-lines, no specific waveform (monophasic orbiphasic) is consistently associated with arate of return of spontaneous circulation(ROSC) or rates of survival to hospital dis-charge after cardiac arrest.

Most lay rescuer AED programs usebiphasic devices. According to the guide-lines, none of the available evidence hasshown superiority of either nonescalating-or escalating-energy biphasic waveforms fortermination of VF. Rather, it is likely thatother factors such as the interval from col-lapse to CPR or defibrillation have a greaterimpact on survival than specific waveformsor energy levels.

For children ages one to eight, a pediatricdose of electrical therapy should be used ifpossible. Some AEDs adjust the dosagethrough pediatric dose-attenuator systems;others use different methods to adjust to apediatric dose. If a child is in VF & a devicewith pediatric capabilities is not available, a standard AED should be used.LIFEPAK 1000 AED with child electrodes

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