National Registry of EMTs’ Implementation of the 2015 AHA Guidelines for CPR and Emergency Cardiovascular Care
In consideration of implementation of the 2015 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC), the National Registry of Emergency Medical Technicians (NREMT) has completed a review of the available published documents to date. The most significant change in the development of the 2015 AHA Guidelines is that this update is based on the International Liaison Committee on Resuscitation’s (ILCOR) comprehensive review of prioritized topics and is not a comprehensive revision of the 2010 Guidelines. Of note, the AHA did incorporate many of the 2010 Guideline recommendations, some of which are included below. The NREMT Standards & Examination Committee has discussed and approved the impact of the recommended changes to all National EMS Certification materials. As previously announced, the NREMT will be implementing the associated recommendations of the 2015 AHA Guidelines for CPR and ECC for all levels of National EMS Certification (NREMR, NREMT, NRAEMT, NRP) beginning September 1, 2016.
The NREMT will continue to require that all candidates for National EMS Certification possess a current and valid CPR credential which is equivalent to the AHA's BLS Provider Course. The following will highlight our understanding of the significant changes contained in the 2015 AHA Guidelines.
Basic Life Support
The NREMT supports the 2015 AHA Guidelines which re-emphasize the sequence for CPR to be C-A-B in unresponsive patients (Compressions, Airway, Breathing). In order to minimize delay in beginning chest compressions, simultaneous breathing and pulse check should be limited to no more than 10 seconds. Healthcare providers should provide both chest compressions and ventilations for victims of cardiopulmonary arrest. Administration of immediate, high-quality CPR is considered of utmost importance which is characterized by:
- Ensuring chest compressions at a rate of at least 100 compressions per minute but no more than 120 compressions per minute for both adult and pediatric patients.
- Ensuring chest compressions at an adequate depth of between 2 – 2.4 inches (5 – 6 cm) in adults and adolescents, 2 inches (5 cm) in children, and 1.5 inches (4 cm) in infants. Chest compression depth should not exceed 2.4 inches (6 cm).
- Allowing full chest recoil between compressions to promote venous return. Avoid leaning on the chest wall between compressions.
- Minimizing interruptions in chest compressions in all patients. For adult patients in cardiac arrest, the goal compression fraction (the percentage of time during the entire resuscitation that compressions are being performed) is 60 – 80%.
- Avoiding excessive ventilation. Without an advanced airway, adult patients should receive CPR using a compression-to-ventilation ratio of 30:2. One rescuer for a pediatric patient should use a 30:2 ratio; however two rescuers should use a 15:2 ratio. With an advanced airway in place, ventilation should be delivered at a rate of 10 per minute for adults and 12 – 20 per minute for pediatric patients. Passive ventilation techniques are not recommended when delivering conventional CPR.
We also note the following BLS recommendations:
- Rapid defibrillation remains a significant focus with a recommendation to use an AED as soon as one is available for adult and pediatric patients. CPR should be provided while the AED is retrieved, attached to the patient, and preparing to analyze the rhythm.
- The use of mechanical compression devices may be considered in settings where the delivery of high-quality CPR is challenging or dangerous for the provider (i.e., in a moving ambulance). However, the evidence does not demonstrate a benefit of mechanical compression devices versus manual compressions in cardiac arrest patients.
- After achieving ROSC, oxygen administration should be adjusted to maintain oxygen saturation levels of at least 94% but less than 100%. (2010 Guideline)
- Neonatal suctioning immediately following birth (including suctioning with a bulb syringe) should be reserved for babies who have obstruction to spontaneous breathing or who require positive pressure ventilation. (2010 Guideline)
- In consideration of the significant public health issue of opioid overdoses, it is appropriate for BLS providers who are properly trained to administer naloxone for opioid-associated resuscitation emergencies if the patient is not in cardiac arrest and if permitted by local regulations. Opioid-associated resuscitative emergencies are defined as the presence of cardiac arrest, respiratory arrest, or severe life-threatening instability due to opiate toxicity. However, any pulseless individual should be managed as a cardiac arrest patient using standard resuscitation measures with a focus on high-quality CPR as described above.
Advanced Cardiovascular Life Support
We also note the following updates to the ACLS recommendations:
- Epinephrine may be administered as quickly as possible following cardiac arrest with a non-shockable rhythm. The use of vasopressin for resuscitation is no longer recommended since outcomes were the same as those when epinephrine was administered.
- Amiodarone or lidocaine may be considered for patients with ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT) that is unresponsive to CPR, defibrillation, and vasopressors. After achieving ROSC from cardiac arrest due to VF or pVT, lidocaine may be considered as an alternative to amiodarone.
- Failure to achieve an EtCO2 greater than 10 mmHg by waveform capnography in an intubated patient after 20 minutes of CPR may be considered as one factor in the decision to terminate resuscitative efforts.
- Atropine should be administered for the initial treatment of bradycardia that produces signs and symptoms of instability (acutely altered mental status, ischemic chest discomfort, acute heart failure, hypotension, or other signs of shock that persist despite adequate airway and breathing). If bradycardia is unresponsive to atropine, IV infusion of beta-adrenergic agonists with rate-accelerating effects (dopamine, epinephrine) or transcutaneous pacing can be effective. (2010 Guideline)
- Immediate transcutaneous pacing might be considered for the treatment of bradycardia in unstable patients who have a high-degree AV block when IV access is not available. (2010 Guideline)
- In the pregnant patient, manual left uterine displacement can be beneficial in relieving aortocaval compression when the fundus height is at or above the level of the umbilicus.
- Out-of-hospital 12-lead ECGs should be acquired for patients who have possible acute coronary syndromes. Interpretation in the field, including the use of computer-assisted ECG interpretations, should be used to determine evidence of STEMI. Providers should notify the receiving facility and/or activate the catheterization laboratory for all patients who have an identified STEMI. Direct transport to a hospital capable of performing percutaneous coronary intervention may be indicated for these patients.
- Use of cold IV fluids after achieving ROSC is not recommended in the out-of-hospital setting. Focus is now placed on in-hospital targeted temperature management.
Pediatric Advanced Life Support
We also note the following updates to the recommendations for management of pediatric patients:
- The early, rapid IV administration of an initial isotonic fluid bolus of 20 mL/kg in children who have hypovolemic or septic shock is recommended. In areas with limited critical care resources, administration of fluid boluses in febrile children should be undertaken with caution and with frequent clinical reassessment.
- Lidocaine or amiodarone are equally acceptable to treat shock-refractory ventricular tachycardia or pulseless ventricular tachycardia in children.
- It is reasonable to use epinephrine during pediatric cardiac arrest. Although epinephrine administration improves ROSC and survival to hospital admission, there is no evidence that treatment with epinephrine improves survival to hospital discharge in pediatric patients.
- Post-resuscitation care for the pediatric patient may include fluids and vasopressors titrated to achieve a systolic blood pressure above the fifth percentile for age. Normoxia should be targeted with oxygen administration weaned to an oxyhemoglobin saturation of 94% to 99%.
Thank you for your interest and support of National EMS Certification. For readily available web access to the integrated 2015 and 2010 AHA Guidelines for CPR and ECC, the reader should visit https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/.