Important updates/changes to management of the Cardiac Arrest patient based on the new 2010 AHA CPR and Emergency cardiac care that are in place are summarized.

1.  Emphasis on high quality Chest compression: Focal point of resuscitation with appropriate early defibrillation.

   • at least 100 times per minute

   • 2" Depth of compression with recoil (Push hard and fast)

   • Minimize Interruptions: Needs to be continuous as much as possible with minimal time on pulse checks (<10secs)

   • Avoid excessive ventillation: 8-10 breaths/minute
     
     

2.  Change from A-B-C to C-A-B
   Untrained single person: Do hands only CPR till help

3.  Chain of Survival:
   Activate EMS  Early CPR ¢ Rapid Defibrillation ¢ Effective advanced life support ¢ Integrated Post-Cardiac Arrest Care

4.  Check breathing/gasping ¢ Responsiveness ¢ Activate EMS/Code and get AED/Defibrillator or send someone ¢ 10 sec pulse check only ¢ start CPR

5.  Avoid Precordial thump in unwitnessed arrest.

6.  Atropine not recommended for routine use in PEA/Asystole. Use Epinephrine early.

7.  Adenosine: OK for initial diagnosis of stable, undifferentiated, regular, monomorphic wide complex tachycardia(WCT) only.  Not other WCT's.

8.  No routine cricoid pressure during ventilation recommended.

9.  1 shock protocol for VF.  Minimize interruption of CPR. Do not wait for rhythm analysis post shock.  Resume CPR immediately

10.  Emphasis on Post- Cardiac Arrest Care:

    • Optimize cardiopulmonary function and vital organ perfusion: Maintain O2 Saturation > 94% ; Treat hypotension effectively.

    • Identify and treat Acute Coronary Syndrome: Get 12 lead EKG ¢ Cardiac Catheterization if appropriate.

    • Therapeutic Hypothermia: Class I Indication: All comatose out of hospital VF arrest should be cooled:
      Mandatory Class IIB indication: All other arrests Non- VF, in-hospital arrests:
      Strongly consider and proceed with cooling if no contraindications

    • Cool 32-34 degrees for 12-24 hours. Passive re-warming.

    • Advanced Critical Care: Anticipate, treat and prevent multi-organ dysfunction.

    • Objectively assess prognosis for recovery.

11.  De-emphasis on devices such as Impedance threshold, Band-CPR in 2010 guideline as failure to show adequate improved outcome to date and delay in CPR except for continuous capnography.
    Studies show 45-71% of out of hospital cardiac arrest have a shockable rhythm(VF/VT) as opposed to only <18% for patients with in-hospital cardiac arrest. 
    Predominant rhythm for in-hospital arrest is Asystole/PEA(>80%).  Thus the importance of effective early CPR.  
    Recent study showed a possibly detrimental effect of AED use vs. manual defibrillator use for in-hospital arrest on survival to discharge, 16.3% vs. 19.3% (JAMA 2010 Nov 15).  This was likely related to interruption of CPR as AEDs require for rhythm interpretation (45-50 sec).