Guideline changes
Defibrillation
There is increased emphasis on the importance of minimally-interrupted
high-quality chest compressions throughout any ALS intervention: chest
compressions are paused briefly only to allow specific interventions.
The recommendation for a specified period of cardiopulmonary resuscitation
(CPR) before out-of-hospital defibrillation, following cardiac arrest
unwitnessed by the emergency medical services (EMS), has been removed.
Chest compressions are now continued while a defibrillator is charged – this
will minimise the pre-shock pause.
The role of the precordial thump is de-emphasised.
The use of up to three quick successive (stacked) shocks is now
recommended for ventricular fibrillation/pulseless ventricular tachycardia
(VF/VT) occurring in the cardiac catheterisation laboratory or in the
immediate post-operative period following cardiac surgery.
Drugs
Delivery of drugs via a tracheal tube is no longer recommended – if
intravenous (IV) access cannot be achieved give drugs by the intraosseous
(IO) route.
When treating VF/VT cardiac arrest, adrenaline 1 mg is given once chest
compressions have restarted after the third shock and then every 3-5 min
(during alternate cycles of CPR). In the 2005 Guidelines, adrenaline was
given just before the third shock. This subtle change in the timing of
adrenaline administration is to separate the timing of drug delivery from
attempted defibrillation. It is hoped that this will result in more efficient shock
delivery and less interruption in chest compressions. Amiodarone 300 mg is
also given after the third shock.
Atropine is no longer recommended for routine use in asystole or pulseless
electrical activity (PEA).
Airway
There is reduced emphasis on early tracheal intubation unless achieved by
highly skilled individuals with minimal interruption to chest compressions.
There is increased emphasis on the use of capnography to confirm and
continually monitor tracheal tube placement, quality of CPR and to provide
an early indication of return of spontaneous circulation (ROSC).
Ultrasound
The potential role of ultrasound imaging during ALS is recognised.
Post-resuscitation care
The potential harm caused by hyperoxaemia after ROSC is achieved is now
recognised: once ROSC has been established and the oxygen saturation of
arterial blood (SaO2) can be monitored reliably (by pulse oximetry and/or
arterial blood gas analysis), inspired oxygen is titrated to achieve a SaO2 of
94 - 98%.
There is much greater detail and emphasis on the treatment of the post-
cardiac-arrest syndrome.
There is recognition that implementation of a comprehensive, structured
post-resuscitation treatment protocol may improve survival in cardiac arrest
victims after ROSC.
There is increased emphasis on the use of primary percutaneous coronary
intervention in appropriate, but comatose, patients with sustained ROSC
after cardiac arrest.
The recommendation for glucose control has been revised: in adults with
sustained ROSC after cardiac arrest, blood glucose values >10 mmol l-1
should be treated but hypoglycaemia must be avoided.
Use of therapeutic hypothermia now includes comatose survivors of cardiac
arrest associated initially with non-shockable rhythms as well as shockable
rhythms. The lower level of evidence for use after cardiac arrest from non-
shockable rhythms is acknowledged.
It is recognised that many of the accepted predictors of poor outcome in
comatose survivors of cardiac arrest are unreliable, especially if the patient
has been treated with therapeutic hypothermia.
