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Easier, More Effective, Evidence-basedGuidelines for Resuscitation: Understandingthe Changes to the Australian Resuscitation

Guidelines 2006Darren Walters, FRACP, FCSANZ, FSCAI ∗

Prince Charles Hospital, Rode Rd., Brisbane, Qld. 4032, Australia

Introduction

The Australian Resuscitation Council (ARC) releasedupdated guidelines for Basic and Advanced Life

Support in March 2006. This followed an extensive inter-national review of resuscitation science conducted by theInternational Liason Committee on Resuscitation (ILCOR)

the last two decades.9 It will require a major change formany organisations involved in the teaching and provisionof BLS including hospitals, ambulance, and paramedicservices. The key changes to basic life support guidelinesare listed in Table 1.10

One of the most fundamental alterations to the BLS hasbeen the recommendation to change to a compression

of which the ARC is a member. The Consensus of Science

and Treatment Recommendations or CoSTR documentformed the evidence-base for the new guidelines.1,2

These recommendations were developed from systematicreviews of the clinical literature incorporating the inputof 281 international resuscitation experts who evaluatedresearch, topics, and hypotheses over a 36-month periodleading up to the 2005 Consensus Conference.1,3–5 TheCardiac Society of Australia and New Zealand is a mem-ber of the ARC and endorses the new guidelines which arebeing phased in by member organisations and health careproviders around the country from August 2006 through2007. Despite a well prepared change management strat-egy for the introduction of the latest guidelines there hasbeen some confusion amongst health care providers andin the popular press as to the substance and rationalebehind the introduction of the new recommendations.6–8

It is important that Cardiologists, Cardiac Surgeons,

ventilation ratio of 30:2 for one and two person operationsin all patients.11–15 The short answer to the question ‘whychange?’ is that the balance of international evidence is thatthe best outcomes are obtained with a faster compressionsrate of 100/min, less ventilation with fewer interruptions.Evidence from studies of CPR provided by trained pro-fessionals using the previous guidelines shows that acombination of inadequate and interrupted chest com-pressions and excessive ventilation, reduce cardiac outputand coronary/cerebral blood flow.11–17 This ultimatelydiminishes the likelihood of success in the resuscitationattempt.

A practical benefit derived from the new recommenda-tions of a 30:2 ratio for all age groups for both one personand two person CPR and the omission of Expired AirResuscitation alone, is a now simpler and easier techniqueto teach and remember.

Pulse checking in the setting of resuscitation from arrest

Cardiac Nurses and Allied health professionals under-stand the new Guidelines so that they may apply bestpractice in the provision of patient care and teach

has been demonstrated to be highly inaccurate even intrained hands and has been associated with operator error

12,18

onsl righ

contemporary techniques of resuscitation to those intraining. The guidelines are freely available on the ARCwebsite http://www.resus.org.au. The principal changes tothe guidelines and insights into why those changes havebeen made are discussed below.

Changes to Basic Life Support (BLS)

The changes to the basic life support guidelines will see thelargest change in resuscitation practice experienced over

Received 13 September 2006; available online 18 December 2006

∗ Tel.: +61 7 3350811; fax: +61 7 33508715.E-mail address: darren walters@health.qld.gov.au.

© 2006 Australasian Society of Cardiac and Thoracic SurgeAustralia and New Zealand. Published by Elsevier Inc. Al

and indecision. Checking for signs of life is as good asattempting to detect the presence or absence of a pulse inan unconscious person. Hence, assessing the pulse is nolonger required.12 There is no evidence that performingchest compression in patients with a spontaneous circu-lation is harmful or arrythmogenic.1,16 Similarly, otheraspects of BLS have been simplified in line with the bestavailable evidence. Unconscious patients can be examinedon their backs or in the position found and are only rolledon the side to facilitate the removal of a definite foreignbody.12–15 To administer chest compressions the hands areplaced in the middle of the chest without measuring for anexact point before compressions are begun.13

The algorithm for BLS is shown in Fig. 1.

and the Cardiac Society ofts reserved.

1443-9506/04/$30.00doi:10.1016/j.hlc.2006.09.014

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Heart, Lung and Circulation Walters 32007;16:2–6 Editorial

Table 1. Summary of basic life support changes10

• ‘No signs of life’ is determined if the patient is unresponsive,not breathing normally and not moving

• Compression ventilation ratio is now 30 compressions to 2 venti-lations regardless of the number of rescuers for infants, childrenand adults

• Chest compressions are at a rate of 100/min• Compressions should occur in the center of the chest: there is

no need to measure the lower half of the sternum• ‘Rescue breathing’ has replaced the term expired air resuscita-

tion (EAR)• CPR = rescue breathing and chest compressions• CPR is given to all patients requiring resuscitation• Two breaths are given instead of five breaths• Defibrillation may be considered part of BLS

Changes to Advanced Life Support (ALS)

The new ALS guidelines have attempted to increaseemphasis on the reversible causes of cardiac arrest thatmay be corrected. The four Hs&Ts gnomonic can act as asimple reminder of conditions that should be sought andcorrected if present19,20:

HypoxameiaHypovolameiaHypo/hyperthermia

F

Hypo/hyperkalaemia & metabolic disordersTamponadeTension pneumothroaxToxins/poisons/drugsThrombosis-pulmonary/coronary

DefibrillationEffective early defibrillation of a ‘shock-able’ rhythm(VF/VT) is a powerful predictor of a successfulresuscitation.19–22 Ventricular fibrillation is the mostfrequent primary arrhythmia in patients with cardiacarrest. With the relatively recent introduction of newbiphasic defibrillators and increasing availability ofautomatic external defibrillators it is not surprising thatmany of the changes in advanced life support relateto facilitating early effective cardioversion.19,22 Thesechanges are summarised in Table 2. The algorithm forALS is shown in Fig. 2.

There has been a clear intention in the new guide-lines to integrate defibrillation with BLS.12 This has beendriven by increasing and more widespread availabilityof user-friendly, reliable automated external defibrillators(AEDs). The success of ‘first responder systems’ in a num-ber of clinical studies demonstrating improved patientoutcomes with the current generation of ‘smart’ AED sys-tems has meant that defibrillation is now considered aBasic Life Support intervention. Defibrillation is taughteasv

raesapipepsdtrsduee

igure 1. The basic life support flow chart.12

T

•••

••

ven in lay community first aid courses where respondentsre instructed that a defibrillator should be obtained asoon as possible, placed on the patient and the machineoice prompts followed.22

The desire to ensure early defibrillation where the defib-illator is available and appropriate needs to be balancedgainst the recognition that (a) it is undesirable to havexcessive time periods without effective chest compres-ion and effective no flow whilst the devices are beingpplied and analyzing the rhythm and (b) the blood flowroduced by a period of CPR prior to defibrillation can

ncrease the success of defibrillation and provide betteratient outcomes.17,22 Hence the guidelines have aimed tomphasise a need to minimise interruptions to chest com-ression by giving a single shock. In general that shockhould be 360 J for a monophasic and 200 J for a biphasicefibrillator as the default settings.19 There is no evidence

hat escalation is superior to non-escalation of shocks inefractory VF.19 The goal of this recommendation is toimplify and standardise attempted defibrillation acrossifferent device manufacturers. In the less common sit-ation, where a manufacturer is able to provide specificvidence-based advice on the energy level that is mostfficacious, this should be used.

able 2. Summary of advanced life support changes10

Give a single rather than stacked shocks for VF/pulseless VTEnergy level for monophasic is 360 J and Biphasic is 200 JAfter each defibrillation give 2 min CPR before recheckingrhythmMinimise interruptions to chest compressionsLook for correctable causes during cardiac arrest

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Figure 2. The advanced life support flow chart.19

If defibrillation is initially unsuccessful it is recom-mended that two minutes of CPR be performed beforeanother attempt at defibrillation. An exception to this iswhere the arrest has been witnessed and attended byhealth care professionals with a manual defibrillator avail-able. In this situation it is reasonable to give up to threeshocks at 360 J (monophasic) or 200 J (biphasic).19

Drug Therapy in Advanced Life SupportThere have been no quantum changes in the recommen-dations for adjuvant dug therapy during cardiac arrest.20,23

VASOPRESSIN. One of the most hotly debated topics in resus-citation medicine is the role of vasopressin in advancedlife support.24 There are no definitive studies to date thatshow that routine administration of any vasopressor atany stage during human cardiac arrest increases rates ofsurvival to hospital discharge. In fact, despite the routinewidespread use of adrenaline in cardiac arrest, there areno placebo controlled studies to support or refute the rou-tine use of any particular drug or drug sequence in thissetting.25 The administration of intravenous vasopressin(40 U) has been compared to adrenaline in five randomisedtrials.25 A meta-analysis of the results failed to demon-strate any significant difference in clinical outcomes foreither patient group.26 In the large multicentre trial con-

ducted by Wenzel et al., post hoc analysis did demonstratean improvement in the survival to hospital dischargewhen vasopressin was used as the initial vasopressor inpatients with asystole.27 Individual resuscitation councilswere left to determine the role of vasopressin in theirresuscitation guidelines. The US guidelines have includedvasopressin as an alternative to adrenaline.28,29 The Aus-tralian guidelines state there is insufficient evidence tosupport or refute vasopressin in ALS and its use has notbeen incorporated into the ALS algorithm.19 Advocatingthe widespread use of vasopressin would have resourceimplications for health care providers.

AMIODARONE. A review of all available evidence failed todemonstrate that any anti-arrhythmic drug given rou-tinely during cardiac arrest increases the rate of survival todischarge from hospital.19,25 Amiodarone given for shockrefractory VF has been shown to be more effective thanlignocaine in improving the rate of survival to hospi-tal admission in patients with an out-of-hospital cardiacarrest.30 There was however, no difference in survival tohospital discharge between the two groups. The evidencefor superiority of amiodarone over lignocaine can thenbe debated. It should be considered in this setting andin the setting of recurrent VF/VT. Lignocaine is an alter-native whose use in cardiac arrest is based on historicalprecedent.

THROMBOLYTICS. The routine use of thrombolytic therapyduring cardiopulmonary resuscitation cannot be sup-ported or refuted from the current available data. Noexcess in bleeding complication has been reported withthe use of these agents in nontraumatic arrests. In selectedcases, thrombolysis may be beneficial if acute massivepulmonary embolism or acute myocardial infarction issuggested to be the cause of the cardiac arrest.19,25,31–33

Post Arrest StrategiesThe use of therapeutic hypothermia with cooling to32–34◦ for 12–24 hours after VF arrest has been shownto improve neurological outcomes for patients.34,35 It isrecommended in this setting but there are some con-cerns this may pose resource and logistical issues fororganisations.23

The importance of glucose control in critically ill patientshas been highlighted in a number of studies but thesestudies have not been specifically performed in the postarrest setting. It has been recommended that blood glu-cose levels should be monitored closely after cardiac arrestand hyperglycaemia corrected with insulin but hypogly-caemia should be avoided.19,25

Medical Emergency Teams (MET)The CoSTR document highlights the emergence of medi-cal emergency teams as a means of preventing in-hospitalcardiac arrests.25 There has been conflicting data onthe utility of this system but it is a promising strategyfor the prevention of cardiac arrest and unplanned ICUadmissions.36 It is recommended that the introduction ofa MET system for adult hospital in-patients be consid-

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Heart, Lung and Circulation Walters 52007;16:2–6 Editorial

Figure 3. The paediatric life support flow chart.37 Figures have beenused with the permission of the ARC.

ered. The intervention has been highlighted as an areafor further research.

Paediatric and Neonatal Advanced Life Support

New guidelines specifically for paediatric and neonataladvanced life support have been developed by the Aus-tralian Resuscitation Council.37,38

The major elements to highlight that are specific toPaediatric Advanced life support are: that a compressionventilation ratio of 15:2 should be used in the hospital set-ting; and defibrillation doses should be 2 J/kg for the firstshock and 4 J/kg for subsequent shocks for monophasicand biphasic devices. The algorithm for PLS is shown inFig. 3.

Conclusion

The Australian Resuscitation Council Guidelines for 2006have been produced by a rigorous evidence-based processthat allows the document to be benchmarked internation-ally. There have been significant changes to the old basicand advanced life support algorithms. The aim of the newtechniques is to provide the most effective strategies for

resuscitation. Techniques that are now easier to teach andremember.

References

1. Proceedings of the 2005 international consensus on car-diopulmonary resuscitation and emergency cardiovascularcare science with treatment recommendations. Resuscitation2005;67(2–3):157–341.

2. Aims and objectives of the Australian Resuscitation Coun-cil; and guideline decision making, process, principles andformat. Emerg Med Australas 2006;18(4):322–4.

3. Morley PT, Zaritsky A. The evidence evaluation processfor the 2005 International Consensus Conference on car-diopulmonary resuscitation and emergency cardiovascularcare science with treatment recommendations. Resuscitation2005;67(2–3):167–70.

4. Proceedings of the 2005 international consensus on cardiopul-monary resuscitation and emergency cardiovascular carescience with treatment recommendations. Part 1. Introduc-tion. Resuscitation 2005;67(2–3):181–6.

5. Chamberlain D, Cummins RO, Montgomery WH, Kloeck WG,Nadkarni VM. International collaboration in resuscitationmedicine. Resuscitation 2005;67(2–3):163–5.

6. Hazinski MF, Nadkarni VM, Hickey RW, O’Connor R, BeckerLB, Zaritsky A. Major changes in the 2005 AHA Guidelines forCPR and ECC: reaching the tipping point for change. Circula-tion 2005;112(Suppl. 24):IV206-11.

7. Kiss of death: paramedics and lifesavers fear new guidelines

could kill patients. Sunday Telegraph; August 13, 2006.

8. Chamberlain D. Are the new resuscitation guidelines opti-mal? Curr Opin Crit Care 2006;12(3):193–7.

9. Agnew P, George P. Surf life saving Australia— circular April2006 change—management for changes to resuscitation; 2006.

10. Jacobs I. New changes to resuscitation guidelines; 2006.http://www.resus.org.au/ (accessed 30/8/2006).

11. Cardiopulmonary resuscitation training: Australian Resus-citation Council Guideline 2004. Emerg Med Australas2006;18(4):335–6.

12. Cardiopulmonary resuscitation: Australian ResuscitationCouncil Guideline 2006. Emerg Med Australas 2006;18(4):332–4.

13. Compressions: Australian Resuscitation Council Guideline2006. Emerg Med Australas 2006;18(4):330–1.

14. Breathing: Australian Resuscitation Council Guideline 2006.Emerg Med Australas 2006;18(4):328–9.

15. Airway: Australian Resuscitation Council Guideline 2006.Emerg Med Australas 2006;18(4):325–7.

16. Proceedings of the 2005 international consensus on cardiopul-monary resuscitation and emergency cardiovascular carescience with treatment recommendations. Part 2. Adult basiclife support. Resuscitation 2005;67(2–3):187–201.

17. White RD. 2005 American Heart Association Guidelines forCardiopulmonary Resuscitation: physiologic and educationalrationale for changes. Mayo Clin Proc 2006;81(6):736–40.

18. Dick WF, Eberle B, Wisser G, Schneider T. The carotid pulsecheck revisited: what if there is no pulse? Crit Care Med2000;28(Suppl. 11):N183–5.

19. Adult advanced life support: Australian Resuscitation CouncilGuidelines 2006. Emerg Med Australas 2006;18(4):337–56.

20. Morley PT, Walker T. Australian Resuscitation Council: adultadvanced life support (ALS) guidelines 2006. Crit Care Resusc2006;8(2):129–31.

21. Larsen MP, Eisenberg MS, Cummins RO, Hallstrom AP. Pre-dicting survival from out-of-hospital cardiac arrest: a graphicmodel. Ann Emerg Med 1993;22(11):1652–8.

ED

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6 Walters Heart, Lung and CirculationEditorial 2007;16:2–6

22. Proceedings of the 2005 international consensus on cardiopul-monary resuscitation and emergency cardiovascular carescience with treatment recommendations. Part 3. Defibrilla-tion. Resuscitation 2005;67(2–3):203–11.

23. Wassertheil J. Australian Resuscitation Guidelines: applyingthe evidence and simplifying the process. Emerg Med Australas2006;18(4):317–21.

24. Nolan JP, Hazinski MF, Steen PA, Becker LB. Controver-sial topics from the 2005 international consensus conferenceon cardiopulmonary resuscitation and emergency cardio-vascular care science with treatment recommendations.Resuscitation 2005;67(2–3):175–9.

25. Proceedings of the 2005 international consensus on cardiopul-monary resuscitation and emergency cardiovascular carescience with treatment recommendations. Part 4. Advancedlife support. Resuscitation 2005;67(2–3):213–47.

26. Aung K, Htay T. Vasopressin for cardiac arrest: a systematicreview and meta-analysis. Arch Intern Med 2005;165(1):17–24.

27. Wenzel V, Krismer AC, Arntz HR, Sitter H, Stadlbauer KH,Lindner KH. A comparison of vasopressin and epinephrinefor out-of-hospital cardiopulmonary resuscitation. N Engl JMed 2004;350(2):105–13.

28. 2005 American Heart Association Guidelines for cardiopul-monary resuscitation and emergency cardiovascular care.Circulation 2005;112(Suppl. 24):IV1-203.

29. Miano TA, Crouch MA. Evolving role of vasopressin in thetreatment of cardiac arrest. Pharmacotherapy 2006;26(6):828–39.

30. Dorian P, Cass D, Schwartz B, Cooper R, Gelaznikas R, Barr A.Amiodarone as compared with lidocaine for shock-resistantventricular fibrillation. N Engl J Med 2002;346(12):884–90.

31. Spohr F, Bottiger BW. Thrombolytics in CPR. Current advan-tages in cardiopulmonary resuscitation. Minerva Anestesiol2005;71(6):291–6.

32. Spohr F, Bottiger BW. Safety of thrombolysis during car-diopulmonary resuscitation. Drug Saf 2003;26(6):367–79.

33. Bottiger BW, Bode C, Kern S, Gries A, Gust R, Glatzer R,Bauer H, Motsch J, Martin E. Efficacy and safety of throm-bolytic therapy after initially unsuccessful cardiopulmonaryresuscitation: a prospective clinical trial. Lancet 2001;357(9268):1583–5.

34. Holzer M, Bernard SA, Hachimi-Idrissi S, Roine RO, Sterz F,Mullner M. Hypothermia for neuroprotection after cardiacarrest: systematic review and individual patient data meta-analysis. Crit Care Med 2005;33(2):414–8.

35. Bernard SA, Gray TW, Buist MD, Jones BM, Silvester W,Gutteridge G, Smith K. Treatment of comatose survivors ofout-of-hospital cardiac arrest with induced hypothermia. NEngl J Med 2002;346(8):557–63.

36. Hillman K, Chen J, Cretikos M, Bellomo R, Brown D, DoigG, Finfer S, Flabouris A. Introduction of the medical emer-gency team (MET) system: a cluster-randomised controlledtrial. Lancet 2005;365(9477):2091–7.

37. Paediatric advanced life support: Australian Resusci-tation Council Guidelines 2006. Emerg Med Australas2006;18(4):357–71.

38. Tibballs J. Australian Resuscitation Council: paediatricadvanced life support (PALS) guidelines 2006. Crit Care Resusc2006;8(2):132–4.