(1) Further emphasize the importance of chest compressions and recommend minimizing the interruption of chest compressions.
(2) Emphasized that “tracking and triggering systems” can detect deteriorating patients and prevent in-hospital cardiac arrests.
(3) Increased awareness of the need for out-of-hospital warning signs related to sudden cardiac death.
(4) No special CPR time points are recommended for out-of-hospital, non-emergency medical provider witnessed electrical defibrillation.
(5) Continuous chest compressions while the defibrillator is being charged, reducing the interval before and after the shock.
(6) De-emphasize the role of precordial pounding.
(7) Use of 3 rapid, continuous shocks in ventricular fibrillation and pulseless ventricular tachycardia immediately after cardiac catheterization or cardiac surgery.
(8) Endotracheal administration is no longer recommended when intravenous access cannot be established and may be administered via the bone marrow cavity route.
(9) In the treatment of ventricular fibrillation or ventricular tachycardia, epinephrine should be given after the 3rd shock, when chest compressions are started again, and then every 3 to 5 min. Amiodarone 300 mg should also be given after the 3rd shock.
(10) Atropine is no longer recommended in the presence of ventricular rest or absence of pulsatile electrical activity.
(11) Decreased importance of early tracheal intubation.
(12) The importance of CO2 mapping was further emphasized. CO2 waveform mapping can confirm the position of tracheal intubation, and continuous monitoring of the position of tracheal intubation and the quality of CPR can provide an early marker for restoration of autonomic circulation.
(13) The potential role of ultrasound imaging in advanced life support was recognized.
(14) The potential harms of hyperoxemia after restoration of autonomic circulation (ROSC) were also recognized. Once autonomic circulation is restored, arterial oxygen saturation should be carefully monitored. The concentration of inhaled oxygen should be titrated to achieve an arterial oxygen saturation of 94% to 98%.
(15) More refinement and emphasis has been placed on the post-cardiac arrest syndrome.
(16) A structured post-resuscitation treatment plan has been recognized to improve survival in patients with cardiac arrest after ROSL
(17) Further emphasis on the use of initial percutaneous coronary intervention in post-ROSL patients (including coma).
(18) Revised recommendations for glycemic control: adults with blood glucose values above 10 mmol/L after ROSC should be treated, but hypoglycemia should be avoided.
(19) Applied therapeutic hypothermia to treat survivors of coma after cardiac arrest.
(20) Recognize that many of the currently accepted predictors are unreliable, especially for those who have been treated with therapeutic hypothermia.
Key Point I Adult Basic Life Support
Initial Artificial Respiration In adults requiring CPR, cardiac arrest is more likely to be of cardiac origin, so CPR should begin with chest compressions. Optimal chest compression techniques include (1) compressing the chest at least 100 times/min at a depth of at least 5 cm, but not more than 6 cm; (2) allowing the chest to rebound sufficiently after each compression; and (3) the time between compressions and relaxation should be approximately equal.
CPR with chest compressions only For trained rescuers and related professionals, chest compressions combined with artificial respiration is the preferred method of performing CPR. If bystanders are unable or unwilling to perform artificial respiration, they should be encouraged to perform chest compressions only, or they should be instructed to perform chest compressions during an emergency call.
Resuscitator risk Resuscitators should be rotated every 2 min to avoid a decrease in the quality of compressions due to resuscitator fatigue. Changing resuscitators should not interrupt chest compressions.
Automatic external defibrillation (AED) is safe and effective for both untrained generalists and professionals. The general population can use AEDs for electrical defibrillation for an extended period of time before the arrival of a professional.
Procedures for performing ECD in public places Automated external defibrillator procedures should be widely used in public places. Studies have shown that CPR performed by police personnel as first responders can result in survival rates of 49% to 74%.
Use of automated external defibrillators Despite limited evidence, automated external defibrillators should be used in hospitals for early electrical defibrillation (target within 3 min of onset). Adequate healthcare personnel should be trained to ensure that patients who experience cardiac arrest anywhere in the hospital can receive the first shock within 3 min.
Manual versus semi-automatic mode shocks Many automated external defibrillators are capable of operating in manual versus semi-automatic mode, but there is no overall difference in ROSC, survival, or discharge rates in the studies that have been performed.
Minimize the pre-shock interval The delay between the cessation of chest compressions and the administration of ECD must be kept within an absolute minimum; even a delay of 5 to 10 s can reduce the success rate of the shock. The pre-shock interval can be reduced to less than 5 s by either continuous chest compressions while the defibrillator is charging or by coordination by the commander to form an efficient team to start chest compressions immediately after the shock, minimizing the post-shock interval. The entire defibrillation process should not interrupt chest compressions for greater than 5 s.
CPR before defibrillation? An analysis of retrospective studies found that emergency medical personnel should perform CPR for approximately 2 min before defibrillation if the patient has been onset for more than 5 min. Performing chest compressions while the defibrillator is recovering and charging has been shown to improve survival. In patients with cardiac arrest without a visual, emergency medical personnel should perform high-quality CPR during defibrillator recovery, application, and recharge, but routine CPR before defibrillation (e.g., 2 to 3 min) is no longer recommended.
1 shock versus 3 consecutive shocks Perform several shocks to defibrillate when defibrillation is required and perform chest compressions immediately after defibrillation. Do not delay in performing rhythm analysis or pulse detection. If ventricular fibrillation/tachycardia occurs after cardiac catheterization or early cardiac surgery (when chest compressions may cause rupture of a vascular suture), give up to 3 clinical defibrillations before starting chest compressions.
Unidirectional versus bidirectional wave defibrillation Currently, bidirectional wave defibrillation has replaced unidirectional wave defibrillators. Compared to unidirectional wave defibrillation, bidirectional wave defibrillation is more effective at first defibrillation. Bidirectional wave defibrillation is also superior to unidirectional wave defibrillation in terms of electrical deflection of atrial fibrillation. Ideally, the first shock energy should not be less than 150 J for defibrillation using all waveforms of bidirectional waves.
Implantable cardioverter-defibrillator A cardioverter-defibrillator should be implanted if the patient is considered to be at risk for life-threatening arrhythmias requiring electric shocks or if such conditions have occurred before. the ICD releases a low level of power and does not cause any harm to the rescuer.
Critical Care Management Patients who are critically ill or likely to become critically ill are usually treated by emergency medical teams, rapid response teams, and critical care outreach teams. The primary basis for a critical care outreach team is a single nurse or a group of nursing staff. The meta-analysis showed that rapid response teams (emergency medical teams) resulted in a reduction in the incidence of out-of-hospital cardiopulmonary respiratory arrest, but had no effect on in-hospital mortality.
Equipment requirements for in-hospital resuscitation All clinical areas should have immediate access to resuscitation equipment and medications to facilitate rapid resuscitation of patients in cardiac and respiratory arrest. Ideally, the equipment used for CPR, as well as medications, should be standardized in placement throughout the hospital.
Key Point 2 Advanced Life Support Treatment Procedures
The new guidelines distinguish between shockable and non-shockable rhythms. Each cycle is roughly similar, and CPR should be given for 2 min before assessing the rhythm and sensing the pulse. epinephrine 1 mg is given every 3-5 min until ROSC is obtained.
Precordial pounding? Precordial pounding is an appropriate treatment only if the physician is present to witness the monitor-monitored cardiac arrest and there is no defibrillator available at hand. In clinical practice, this is only feasible in the intensive care setting.
Intravenous access? If intravenous access is still not available, then it should be established. Peripheral administration must be followed by at least 20 ml of fluid flush. If intravenous access is difficult or impossible to establish, bone marrow cavity access should be considered.
Atropine? Ventricular quiescence is usually due to a primary myocardial lesion and is not associated with excessive vagal tone. Atropine is no longer routinely recommended in the presence of ventricular quiescence or absence of pulsatile electrical activity.
Advanced life support ultrasound applications? With a clinician trained in ultrasound, the application of ultrasound can help identify potentially reversible causes of cardiac arrest and help treat those causes. Ultrasound access to advanced life support therapy requires extensive training and should minimize the interruption of chest compressions. Guidelines have recommended the use of a fenestrated probe position, which should be placed prior to the pause in chest compressions (when a cardiac rhythm assessment is planned), and a well-trained operator can obtain results within 10 s.
Airway Management and Ventilation? Data suggest that high arterial oxygen saturation after ROSC is prognostically unfavorable. Oxygen should be inhaled once the arterial oxygen saturation is accurately measured to achieve an arterial oxygen saturation of 94% to 98%.
Confirmation of tracheal intubation position CO2 waveform mapping is the most sensitive and specific method to confirm the position of tracheal intubation and monitor it continuously, complementing the clinical assessment (auscultation versus visualization during tracheal intubation through the vocal cords). Available handheld CO2 waveform monitors can confirm that tracheal intubation is in place under a variety of environmental conditions. In the absence of a CO2 waveform monitor, it is recommended that advanced airway management measures should preferably be applied with an acoustic supraglottic airway device.
Key point III Post-resuscitation treatment
Successful restoration of autonomic circulation is only the first step to complete resuscitation after cardiac arrest. Post-cardiac arrest syndrome often complicates late resuscitation and includes post-cardiac arrest brain injury, post-cardiac arrest myocardial function injury, systemic ischemia/reperfusion response, and ongoing progressive injury. Severe myocardial dysfunction often occurs after cardiac arrest, but normalization usually occurs after 2 to 3 d. The systemic ischemia/reperfusion response after cardiac arrest activates the immune system and the coagulation system, and activation of these two systems can lead to multi-organ failure and increase the chance of infection. Thus, the post-cardiac arrest syndrome often shares many features with sepsis.
Circulation Coronary intervention should be considered in all patients with cardiac arrest who are suspected of having coronary artery disease. Studies have shown that the combination of therapeutic hypothermia and PCI is safe and feasible for cardiac arrest due to acute myocardial infarction.
Glycemic control Based on current evidence, glycemic values should be controlled to 10 mmol/L after resumption of autonomic circulation and hypoglycemia should be avoided. In patients recovering from cardiac arrest, tight glycemic control may increase the risk of hypoglycemia, and therefore a strict glycemic control strategy is not recommended.
Therapeutic hypothermia? Animal and human studies have shown that mild hypothermia is neuroprotective and can improve the prognosis of whole brain ischemia and hypoxia. Hypothermia can inhibit many pathways that can cause cell death, reduce the rate of oxygen metabolism in brain tissue and decrease the inflammatory response associated with post-cardiac arrest syndrome. Animal data suggest that the earlier hypothermia is performed after the return of autonomic circulation, the better the prognosis. During the temperature maintenance period, cooling with effective temperature monitoring may be preferred to avoid temperature fluctuations. Rewarming must be done slowly, and the current consensus recommendation is 0.25-0.5°C per hour.
Chest pain observation protocol? Monitoring arterial oxygen saturation using a pulse oximeter is helpful in determining the need for oxygen administration. If the patient is not hypoxemic, no additional oxygen is required. Limited data suggest that high-flow oxygenation is harmful in patients with uncomplicated myocardial infarction. The target value for arterial oxygen saturation is 94% to 98%, or 88% to 92% if the patient is at risk for hypercapnic respiratory failure.
Key point IV Pediatric life support
Within 10 s after cardiac arrest, medical personnel can diagnose cardiac arrest by increasing palpation of the pulse to determine whether chest compressions should be initiated. Depending on the age of the child, carotid (children), brachial (infants and children), or femoral pulses (children or infants) may be applied for detection, but the decision to perform CPR must be made within 10 s.
The compression to ventilation ratio in children depends on whether it is a single rescuer or multiple rescuers. A 30:2 compression to ventilation ratio should be used for lay rescuers. Rescuers who are unable or unwilling to perform mouth-to-mouth manual ventilation should be encouraged to perform CPR with chest compressions.
It is emphasized that high-quality compressions should be of adequate depth and that interruptions in compressions and no-flow time should be minimized. In all children, chest compressions should be at least 1/3 of the anteroposterior diameter of the chest in depth (close to 4 cm in infants and 5 cm in children) and should be completely relaxed after each compression. For infants and children, the number of compressions should be at least 100 but not more than 120 compressions/min. Compression techniques include single two-finger compressions and two-thumb around methods for two or more people. For older children, either the one- or two-handed technique can be used.
For children over 1 year of age, application of automated external defibrillation is safe and effective. For children 1 to 8 years of age, it is recommended that the output energy of the machine be reduced to 50-75 J using a relevant performance analysis system or software. unmodified adult external automatic defibrillators can also be applied in children older than 1 year of age if the shock energy cannot be reduced or if manual adjustment is not possible. In some rare cases, it is also reasonable to apply a shock with an external automatic defibrillator in children under 1 year of age (preferably with a dose attenuator).
To reduce the no-flow time, chest compressions should be continued while the manual defibrillator is applied to defibrillate and charge the electrode plates (if the size of the child’s chest allows). Chest compressions can be suspended once the defibrillator is charged and ready to deliver a shock. A single shock strategy with a dose of 4 J/kg is recommended for defibrillation in children (preferably a bidirectional wave, but a unidirectional wave may also be applied). It is safe to apply sleeve tracheal intubation in infants and younger children. A validated formula can be applied to select the size of the tracheal tube.
The safety and value of applying cricoid cartilage compressions during tracheal intubation is unknown. If cricoid cartilage compressions impede ventilation or reduce the speed and make tracheal intubation more difficult, cricoid cartilage compressions should be modified or interrupted.
Monitoring end-expiratory CO2 (which can be achieved by CO2 waveform mapping) can help confirm the position of tracheal intubation. Monitoring end-expiratory CO2 during CPR helps to assess the quality of compressions and to optimize the compression process. Once ROSC has occurred, the concentration of inhaled oxygen should be titrated to limit the dangers of hyperoxemia. In the pediatric inpatient setting, the use of rapid response systems can reduce the incidence of in-hospital cardiac arrest and respiratory arrest, and also reduce in-hospital mortality.
Key point V. Resuscitation of infants at delivery
(1) For uninjured infants, the guidelines recommend a delay of at least 1 minute after complete delivery before cutting the umbilical cord. There is insufficient evidence to recommend an appropriate time to cut the umbilical cord for infants who have been severely injured during delivery.
(2) For full-term infants, air should be used for resuscitation at delivery. If ventilation has been given but oxygenation is still unacceptable, then high concentrations of oxygen should be considered.
(3) Preterm infants born at less than 32 weeks’ gestation do not obtain the same transcutaneous oxygen saturation in air as full-term infants. Therefore, a mixture of oxygen and air should be given with caution and may be guided by the use of a pulse oximeter. If a gas mixture of air and oxygen is not available, an accessible gas should be used.
(4) Premature infants born at less than 28 weeks gestation should be completely wrapped (up to the neck) in food-grade plastic wrap or plastic bag immediately after birth and do not need to be dried. They should then be cared for under a radiant heater until stable. The temperature of the delivery room for preterm infants should be at least 26°C.
(5) The recommended ratio of compressions to ventilation for neonatal resuscitation is 3:1.
(6) Suctioning meconium from the unborn infant’s mouth and nose is not recommended while the infant’s head is still in the perineum. If the infant presents with muscle relaxation and asphyxia after birth, the infant’s oropharynx should be examined quickly and the obstruction removed if possible. Tracheal intubation with suctioning may be beneficial. However, if tracheal intubation takes too long or is unsuccessful, especially if there is persistent bradycardia, immediate mask ventilation should be given.
(7) If epinephrine is to be given intravenously, the recommended dose is 10-30 μg/kg. If administered via tracheal intubation, the likely dose is 50-100 μg/kg, which may be equivalent to the efficacy of the intravenous dose.
(8) In addition to clinical evaluation, monitoring of end-expiratory CO2 is recommended for neonates with ROSC as the most reliable way to confirm the appropriateness of the tracheal intubation position.
(9) Newborns born at or near term with moderate-to-severe ischemic-hypoxic encephalopathy should be considered for treatment with therapeutic hypothermia, if possible.
Key point VI ACS initialization management
(1) The term “non-ST-segment elevation myocardial infarction-acute coronary syndrome” has been extended to non-ST-segment elevation myocardial infarction and unstable angina pectoris.
(2) History, clinical examination, biomarkers, ECG criteria and risk scores are not reliable for early and safe identification of patients.
(3) The chest pain observation clinic is designed to identify patients who require hospitalization for invasive treatment, and available methods include repeated clinical examination, ECG and biomarker testing. Stimulation tests and imaging measures (e.g., cardiac CT scan, MRI, etc.) may also be used in some patients.
(4) Avoid non-steroidal anti-inflammatory drugs.
(5) Nitrates should not be used for diagnostic purposes.
(6) Oxygen supplementation therapy is indicated only for patients with hypoxemia, shortness of breath, or pulmonary stasis; hyperoxemia may be harmful in some patients with uncomplicated heart attacks.
(7) The use of aspirin for the treatment of acute coronary syndrome (ACS) has become more expansive. Aspirin can be given by a bystander with or without the help of an emergency medical provider.
(8) Guidelines have been revised for the application of antiplatelet and anticoagulation therapy for ST-segment elevation myocardial infarction and non-ST elevation acute coronary syndromes.
(9) The application of platelet IIb/IIIa receptor antagonists before angiography or percutaneous coronary intervention is not recommended.
(10) The reperfusion strategy for ST-segment elevation myocardial infarction is updated as follows: (i) if direct PCI (PPCI) is done by an experienced team, it can be the preferred reperfusion strategy; (ii) if direct PCI can be obtained without too long a delay, the medical staff can bypass a nearby hospital; (iii) the acceptable delay between the start of thrombolysis and the first balloon dilation varies very much (iii) the acceptable delay between the start of thrombolysis and the first balloon dilation is very variable, usually 45 to 180 min, depending on the location of the infarct, the age of the patient, and the duration of symptoms; (iv) if thrombolysis fails, then salvage PCI should be performed, and PCI is not recommended routinely after thrombolysis (easy PCI); (v) if the hospital cannot perform PCI, then transfer to another hospital for angiography and eventual PCI after successful thrombolysis. The optimal time is 6 to 24 h after thrombolysis (drug-invasive approach); (6) for patients with ROSC after cardiac arrest, angiography and PCI (if necessary) are reasonable and they are part of a standardized treatment plan after cardiac arrest; (7) to achieve these goals, the creation of a medical network is beneficial; (8) more stringent application of β-blockers is recommended: there is no evidence to confirm the benefit of intravenous application of β- receptor blockers, except in some specific cases (e.g., tachyarrhythmia). Beta-blockers should be started at low doses only after the patient has stabilized;9 the guideline recommendations for the application of prophylactic antiarrhythmic drugs, ACEI/ARBs, and statins remain unchanged.
Key point VII ACS treatment strategies
Acetylsalicylic acid Aspirin should be given as early as possible to all patients with suspected acute coronary syndrome unless the patient has a definite allergy to aspirin.
Anticoagulation Enoxaparin is a safe and effective alternative to regular heparin. There is insufficient evidence to confirm the use of low molecular heparins other than enoxaparin for coronary intervention in patients with ST-segment elevation myocardial infarction.
Direct PCI Several studies and meta-analyses have confirmed that direct PCI is superior to thrombolytic therapy in several endpoints (death, stroke, recurrent infarction), so coronary angiography (with or without stenting) has become the first-line treatment for patients with ST-segment elevation myocardial infarction.
How easy is it to combine thrombolytic therapy with PCI? PCI is defined as PCI performed immediately after thrombolysis; drug-invasive strategy is defined as PCI performed routinely within 3 to 24 h after thrombolysis; remedial PCI is defined as PCI performed after reperfusion failure (based on less than 50% decrease in the elevated ST segment after 60 to 90 min of thrombolytic therapy). Routine PCI immediately after thrombolysis or as early as possible can lead to a worse prognosis, and easy PCI treatment is not recommended routinely. Successful clinical thrombolysis (based on clinical signs and ST-segment drop of more than 50%) confirms that angiography performed with a delay of several hours after thrombolysis improves the prognosis (drug-invasive approach).
Reperfusion therapy after successful CPR Immediate thrombolysis or angiography and PCI should be considered in patients with out-of-hospital cardiac arrest who have regained autonomic circulation, if the ECG shows ST-segment elevation myocardial infarction or new left bundle branch block. reperfusion therapy strategy should not exclude other therapeutic strategies (e.g. therapeutic hypothermia).
Editor’s Note
The 2010 CPR guidelines were agreed upon by the International Resuscitation Federation and the American Heart Association at a recommendation meeting held in Dallas, USA, in February 2010. However, the US and European guidelines have their own focus, with the US guidelines focusing on theoretical analysis and reproducing evidence, while the European guidelines are more focused on guiding clinicians on specific operations. We have published the interpretation of the US CPR guidelines in General Issue 186 and General Issue 188. In order to provide readers with a more comprehensive understanding of the new guidelines, we have published the highlights of the 2010 European CPR guidelines (Resuscitation. 2010, 81:1219) in this issue, aiming to deliver the latest information to our readers.