2010心肺复苏指南

ISSN: 1524-4539 Copyright © 2010 American Heart Association. All rights reserved. Print ISSN: 0009-7322. Online 72514 Circulation is published by the American Heart Association. 7272 Greenville Avenue, Dallas, TX DOI: 10.1161/CIRCULATIONAHA.110.970889 2010;122;S640-S656 Circulation Hoek Callaway, Brett Cucchiara, Jeffrey D. Ferguson, Thomas D. Rea and Terry L. Vanden Mark S. Link, Laurie J. Morrison, Robert E. O'Connor, Michael Shuster, Clifton W. Marc D. Berg, John E. Billi, Brian Eigel, Robert W. Hickey, Monica E. Kleinman, Neumar, Mary Ann Peberdy, Jeffrey M. Perlman, Elizabeth Sinz, Andrew H. Travers, Farhan Bhanji, Diana M. Cave, Edward C. Jauch, Peter J. Kudenchuk, Robert W. Schexnayder, Robin Hemphill, Ricardo A. Samson, John Kattwinkel, Robert A. Berg, John M. Field, Mary Fran Hazinski, Michael R. Sayre, Leon Chameides, Stephen M. Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 1: Executive Summary: 2010 American Heart Association Guidelines for http://circ.ahajournals.org/cgi/content/full/122/18_suppl_3/S640 located on the World Wide Web at: The online version of this article, along with updated information and services, is http://www.lww.com/reprints Reprints: Information about reprints can be found online at journalpermissions@lww.com 410-528-8550. E-mail: Fax:Kluwer Health, 351 West Camden Street, Baltimore, MD 21202-2436. Phone: 410-528-4050. Permissions: Permissions & Rights Desk, Lippincott Williams & Wilkins, a division of Wolters http://circ.ahajournals.org/subscriptions/ Subscriptions: Information about subscribing to Circulation is online at by on October 21, 2010 circ.ahajournals.orgDownloaded from Part 1: Executive Summary 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care John M. Field, Co-Chair*; Mary Fran Hazinski, Co-Chair*; Michael R. Sayre; Leon Chameides; Stephen M. Schexnayder; Robin Hemphill; Ricardo A. Samson; John Kattwinkel; Robert A. Berg; Farhan Bhanji; Diana M. Cave; Edward C. Jauch; Peter J. Kudenchuk; Robert W. Neumar; Mary Ann Peberdy; Jeffrey M. Perlman; Elizabeth Sinz; Andrew H. Travers; Marc D. Berg; John E. Billi; Brian Eigel; Robert W. Hickey; Monica E. Kleinman; Mark S. Link; Laurie J. Morrison; Robert E. O’Connor; Michael Shuster; Clifton W. Callaway; Brett Cucchiara; Jeffrey D. Ferguson; Thomas D. Rea; Terry L. Vanden Hoek The publication of the 2010 American Heart AssociationGuidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care marks the 50th anniversary of modern CPR. In 1960 Kouwenhoven, Knickerbocker, and Jude documented 14 patients who survived cardiac arrest with the application of closed chest cardiac massage.1 That same year, at the meeting of the Maryland Medical Society in Ocean City, MD, the combination of chest compressions and rescue breathing was introduced.2 Two years later, in 1962, direct-current, monophasic waveform defibrillation was de- scribed.3 In 1966 the American Heart Association (AHA) developed the first cardiopulmonary resuscitation (CPR) guidelines, which have been followed by periodic updates.4 During the past 50 years the fundamentals of early recogni- tion and activation, early CPR, early defibrillation, and early access to emergency medical care have saved hundreds of thousands of lives around the world. These lives demonstrate the importance of resuscitation research and clinical transla- tion and are cause to celebrate this 50th anniversary of CPR. Challenges remain if we are to fulfill the potential offered by the pioneer resuscitation scientists. We know that there is a striking disparity in survival outcomes from cardiac arrest across systems of care, with some systems reporting 5-fold higher survival rates than others.5–9 Although technology, such as that incorporated in automated external defibrillators (AEDs), has contributed to increased survival from cardiac arrest, no initial intervention can be delivered to the victim of cardiac arrest unless bystanders are ready, willing, and able to act. Moreover, to be successful, the actions of bystanders and other care providers must occur within a system that coordi- nates and integrates each facet of care into a comprehensive whole, focusing on survival to discharge from the hospital. This executive summary highlights the major changes and most provocative recommendations in the 2010 AHA Guide- lines for CPR and Emergency Cardiovascular Care (ECC). The scientists and healthcare providers participating in a comprehensive evidence evaluation process analyzed the sequence and priorities of the steps of CPR in light of current scientific advances to identify factors with the greatest potential impact on survival. On the basis of the strength of the available evidence, they developed recommendations to support the interventions that showed the most promise. There was unanimous support for continued emphasis on high-quality CPR, with compressions of adequate rate and depth, allowing complete chest recoil, minimizing inter- ruptions in chest compressions and avoiding excessive ventilation. High-quality CPR is the cornerstone of a system of care that can optimize outcomes beyond return of spontaneous circulation (ROSC). Return to a prior quality of life and functional state of health is the ultimate goal of a resuscitation system of care. The 2010 AHA Guidelines for CPR and ECC are based on the most current and comprehensive review of resuscitation litera- ture ever published, the 2010 ILCOR International Consensus on CPR and ECC Science With Treatment Recommendations.10 The 2010 evidence evaluation process included 356 resuscita- tion experts from 29 countries who reviewed, analyzed, evalu- ated, debated, and discussed research and hypotheses through in-person meetings, teleconferences, and online sessions (“web- inars”) during the 36-month period before the 2010 Consensus Conference. The experts produced 411 scientific evidence re- views on 277 topics in resuscitation and emergency cardiovas- cular care. The process included structured evidence evaluation, analysis, and cataloging of the literature. It also included rigor- The American Heart Association requests that this document be cited as follows: Field JM, Hazinski MF, Sayre MR, Chameides L, Schexnayder SM, Hemphill R, Samson RA, Kattwinkel J, Berg RA, Bhanji F, Cave DM, Jauch EC, Kudenchuk PJ, Neumar RW, Peberdy MA, Perlman JM, Sinz E, Travers AH, Berg MD, Billi JE, Eigel B, Hickey RW, Kleinman ME, Link MS, Morrison LJ, O’Connor RE, Shuster M, Callaway CW, Cucchiara B, Ferguson JD, Rea TD, Vanden Hoek TL. Part 1: executive summary: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(suppl 3):S640–S656. *Co-chairs and equal first co-authors. (Circulation. 2010;122[suppl 3]:S640–S656.) © 2010 American Heart Association, Inc. Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIRCULATIONAHA.110.970889 S640 by on October 21, 2010 circ.ahajournals.orgDownloaded from ous disclosure and management of potential conflicts of interest, which are detailed in Part 2: “Evidence Evaluation and Man- agement of Potential and Perceived Conflicts of Interest.” The recommendations in the 2010 Guidelines confirm the safety and effectiveness of many approaches, acknowledge ineffectiveness of others, and introduce new treatments based on intensive evidence evaluation and consensus of experts. These new recommendations do not imply that care using past guidelines is either unsafe or ineffective. In addition, it is important to note that they will not apply to all rescuers and all victims in all situations. The leader of a resuscitation attempt may need to adapt application of these recommenda- tions to unique circumstances. New Developments in Resuscitation Science Since 2005 A universal compression-ventilation ratio of 30:2 performed by lone rescuers for victims of all ages was one of the most controversial topics discussed during the 2005 International Consensus Conference, and it was a major change in the 2005 AHA Guidelines for CPR and ECC.11 In 2005 rates of survival to hospital discharge from witnessed out-of-hospital sudden cardiac arrest due to ventricular fibrillation (VF) were low, averaging !6% worldwide with little improvement in the years immediately preceding the 2005 conference.5 Two studies published just before the 2005 International Consen- sus Conference documented poor quality of CPR performed in both out-of-hospital and in-hospital resuscitations.12,13 The changes in the compression-ventilation ratio and in the defibrillation sequence (from 3 stacked shocks to 1 shock followed by immediate CPR) were recommended to mini- mize interruptions in chest compressions.11–13 There have been many developments in resuscitation science since 2005, and these are highlighted below. Emergency Medical Services Systems and CPR Quality Emergency medical services (EMS) systems and healthcare providers should identify and strengthen “weak links” in the Chain of Survival. There is evidence of considerable regional variation in the reported incidence and outcome from cardiac arrest within the United States.5,14 This evidence supports the importance of accurately identifying each instance of treated cardiac arrest and measuring outcomes and suggests additional opportunities for improving survival rates in many communities. Recent studies have demonstrated improved outcome from out-of-hospital cardiac arrest, particularly from shockable rhythms, and have reaffirmed the importance of a stronger emphasis on compressions of adequate rate and depth, allowing complete chest recoil after each compression, minimizing interrup- tions in compressions and avoiding excessive ventilation.15–22 Implementation of new resuscitation guidelines has been shown to improve outcomes.18,20–22 A means of expediting guidelines implementation (a process that may take from 18 months to 4 years23–26) is needed. Impediments to implemen- tation include delays in instruction (eg, time needed to produce new training materials and update instructors and providers), technology upgrades (eg, reprogramming AEDs), and decision making (eg, coordination with allied agencies and government regulators, medical direction, and participa- tion in research). Documenting the Effects of CPR Performance by Lay Rescuers During the past 5 years there has been an effort to simplify CPR recommendations and emphasize the fundamental importance of high-quality CPR. Large observational studies from investiga- tors in member countries of the Resuscitation Council of Asia (the newest member of ILCOR)27,28–30 and other studies31,32 have provided important information about the positive impact of bystander CPR on survival after out-of-hospital cardiac arrest. For most adults with out-of-hospital cardiac arrest, bystander CPR with chest compression only (Hands-Only CPR) appears to achieve outcomes similar to those of conventional CPR (com- pressions with rescue breathing).28–32 However, for children, conventional CPR is superior.27 CPR Quality Minimizing the interval between stopping chest compressions and delivering a shock (ie, minimizing the preshock pause) improves the chances of shock success33,34 and patient sur- vival.33–35 Data downloaded from CPR-sensing and feedback- enabled defibrillators provide valuable information to resus- citation teams, which can improve CPR quality.36 These data are driving major changes in the training of in-hospital resuscitation teams and out-of-hospital healthcare providers. In-Hospital CPR Registries The National Registry of CardioPulmonary Resuscitation (NRCPR)37 and other large databases are providing new infor- mation about the epidemiology and outcomes of in-hospital resuscitation in adults and children.8,38–44 Although observa- tional in nature, registries provide valuable descriptive informa- tion to better characterize cardiac arrest and resuscitation out- comes as well as identify areas for further research. Deemphasis on Devices and Advanced Cardiovascular Life Support Drugs During Cardiac Arrest At the time of the 2010 International Consensus Conference there were still insufficient data to demonstrate that any drugs or mechanical CPR devices improve long-term outcome after cardiac arrest.45 Clearly further studies, adequately powered to detect clinically important outcome differences with these interventions, are needed. Importance of Post–Cardiac Arrest Care Organized post–cardiac arrest care with an emphasis on multidisciplinary programs that focus on optimizing hemo- dynamic, neurologic, and metabolic function (including ther- apeutic hypothermia) may improve survival to hospital dis- charge among victims who achieve ROSC following cardiac arrest either in- or out-of-hospital.46–48 Although it is not yet possible to determine the individual effect of many of these therapies, when bundled as an integrated system of care, their deployment may well improve outcomes. Therapeutic hypothermia is one intervention that has been shown to improve outcome for comatose adult victims of Field et al Part 1: Executive Summary S641 by on October 21, 2010 circ.ahajournals.orgDownloaded from witnessed out-of-hospital cardiac arrest when the presenting rhythm was VF.49,50 Since 2005, two nonrandomized studies with concurrent controls as well as other studies using historic controls have indicated the possible benefit of hypo- thermia following in- and out-of-hospital cardiac arrest from all other initial rhythms in adults.46,51–56 Hypothermia has also been shown to be effective in improving intact neurologic survival in neonates with hypoxic-ischemic encephalopa- thy,57–61 and the results of a prospective multicenter pediatric study of therapeutic hypothermia after cardiac arrest are eagerly awaited. Many studies have attempted to identify comatose post– cardiac arrest patients who have no prospect for meaningful neurologic recovery, and decision rules for prognostication of poor outcome have been proposed.62 Therapeutic hypother- mia changes the specificity of prognostication decision rules that were previously established from studies of post–cardiac arrest patients not treated with hypothermia. Recent reports have documented occasional good outcomes in post–cardiac arrest patients who were treated with therapeutic hypother- mia, despite neurologic exam or neuroelectrophysiologic studies that predicted poor outcome.63,64 Education and Implementation The quality of rescuer education and frequency of retraining are critical factors in improving the effectiveness of resusci- tation.65–83 Ideally retraining should not be limited to 2-year intervals. More frequent renewal of skills is needed, with a commitment to maintenance of certification similar to that embraced by many healthcare-credentialing organizations. Resuscitation interventions are often performed simulta- neously, and rescuers must be able to work collaboratively to minimize interruptions in chest compressions. Teamwork and leadership skills continue to be important, particularly for advanced cardiovascular life support (ACLS) and pediatric advanced life support (PALS) providers.36,84–89 Community and hospital-based resuscitation programs should systematically monitor cardiac arrests, the level of resuscitation care provided, and outcome. The cycle of measurement, interpretation, feedback, and continuous qual- ity improvement provides fundamental information necessary to optimize resuscitation care and should help to narrow the knowledge and clinical gaps between ideal and actual resus- citation performance. Highlights of the 2010 Guidelines The Change From “A-B-C” to “C-A-B” The newest development in the 2010 AHA Guidelines for CPR and ECC is a change in the basic life support (BLS) sequence of steps from “A-B-C” (Airway, Breathing, Chest compressions) to “C-A-B” (Chest compressions, Airway, Breathing) for adults and pediatric patients (children and infants, excluding newly borns). Although the experts agreed that it is important to reduce time to first chest compressions, they were aware that a change in something as established as the A-B-C sequence would require re-education of everyone who has ever learned CPR. The 2010 AHA Guidelines for CPR and ECC recommend this change for the following reasons: ● The vast majority of cardiac arrests occur in adults, and the highest survival rates from cardiac arrest are reported among patients of all ages with witnessed arrest and a rhythm of VF or pulseless ventricular tachycardia (VT). In these patients the critical initial elements of CPR are chest compressions and early defibrillation.90 ● In the A-B-C sequence chest compressions are often delayed while the responder opens the airway to give mouth-to-mouth breaths or retrieves a barrier device or other ventilation equipment. By changing the sequence to C-A-B, chest compressions will be initiated sooner and ventilation only minimally delayed until completion of the first cycle of chest compressions (30 compressions should be accomplished in approximately 18 seconds). ● Fewer than 50% of persons in cardiac arrest receive bystander CPR. There are probably many reasons for this, but one impediment may be the A-B-C sequence, which starts with the procedures that rescuers find most difficult: opening the airway and delivering rescue breaths. Starting with chest compressions might ensure that more victims receive CPR and that rescuers who are unable or unwilling to provide ventilations will at least perform chest compressions. ● It is reasonable for healthcare providers to tailor the sequence of rescue actions to the most likely cause of arrest. For example, if a lone healthcare provider sees a victim suddenly collapse, the provider may assume that the victim has suffered a sudden VF cardiac arrest; once the provider has verified that the victim is unresponsive and not breathing or is only gasping, the provider should immediately activate the emergency response system, get and use an AED, and give CPR. But for a presumed victim of drowning or other likely asphyxial arrest the priority would be to provide about 5 cycles (about 2 minutes) of conventional CPR (including rescue breathing) before ac- tivating the emergency response system. Also, in newly born infants, arrest is more likely to be of a respiratory etiology, and resuscitation should be attempted with the A-B-C sequence unless there is a known cardiac etiology. Ethical Issues The ethical issues surrounding resuscitation are complex and vary across settings (in- or out-of-hospital), providers (basic or advanced), and whether to start or how to terminate CPR. Recent work suggests that acknowledgment of a verbal do-not-attempt- resuscitation order (DNAR) in addition to the current stan- dard—a written, signed, and dated DNAR document—may decrease the number of futile resuscitation attempts.91,92 This is an important first step in expanding the clinical decision rule pertaining to when to start resuscitation in out-of-hospital car- diac arrest. However, there is insufficient evidence to support this approach without further validation. When only BLS-trained EMS personnel are available, termination of resuscitative efforts should be guided by a validated termination of resuscitation rule that reduces the transport rate of attempted resuscitations without compro- mising the care of potentially viable patients.93 Advanced life support (ALS) EMS providers may use the same termination of resuscitation rule94 –99 or a derived nonvali- dated rule specific to ALS providers that when applied will S642 Circulation November 2, 2010 by on October 21, 2010 circ.ahajournals.orgDownloaded from decrease the number of futile transports to the emergency department (ED).95,97–100 Certain characteris