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W4365364786 abstract "HomeCirculationVol. 122, No. 16_suppl_2Part 1: Executive Summary Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBPart 1: Executive Summary2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Mary Fran Hazinski, Jerry P. Nolan, John E. Billi, Bernd W. Böttiger, Leo Bossaert, Allan R. de Caen, Charles D. Deakin, Saul Drajer, Brian Eigel, Robert W. Hickey, Ian Jacobs, Monica E. Kleinman, Walter Kloeck, Rudolph W. Koster, Swee Han Lim, Mary E. Mancini, William H. Montgomery, Peter T. Morley, Laurie J. Morrison, Vinay M. Nadkarni, Robert E. O'Connor, Kazuo Okada, Jeffrey M. Perlman, Michael R. Sayre, Michael Shuster, Jasmeet Soar, Kjetil Sunde, Andrew H. Travers, Jonathan Wyllie and David Zideman Mary Fran HazinskiMary Fran Hazinski *Co-chairs and equal first co-authors. Search for more papers by this author , Jerry P. NolanJerry P. Nolan *Co-chairs and equal first co-authors. Search for more papers by this author , John E. BilliJohn E. Billi Search for more papers by this author , Bernd W. BöttigerBernd W. Böttiger Search for more papers by this author , Leo BossaertLeo Bossaert Search for more papers by this author , Allan R. de CaenAllan R. de Caen Search for more papers by this author , Charles D. DeakinCharles D. Deakin Search for more papers by this author , Saul DrajerSaul Drajer Search for more papers by this author , Brian EigelBrian Eigel Search for more papers by this author , Robert W. HickeyRobert W. Hickey Search for more papers by this author , Ian JacobsIan Jacobs Search for more papers by this author , Monica E. KleinmanMonica E. Kleinman Search for more papers by this author , Walter KloeckWalter Kloeck Search for more papers by this author , Rudolph W. KosterRudolph W. Koster Search for more papers by this author , Swee Han LimSwee Han Lim Search for more papers by this author , Mary E. ManciniMary E. Mancini Search for more papers by this author , William H. MontgomeryWilliam H. Montgomery Search for more papers by this author , Peter T. MorleyPeter T. Morley Search for more papers by this author , Laurie J. MorrisonLaurie J. Morrison Search for more papers by this author , Vinay M. NadkarniVinay M. Nadkarni Search for more papers by this author , Robert E. O'ConnorRobert E. O'Connor Search for more papers by this author , Kazuo OkadaKazuo Okada Search for more papers by this author , Jeffrey M. PerlmanJeffrey M. Perlman Search for more papers by this author , Michael R. SayreMichael R. Sayre Search for more papers by this author , Michael ShusterMichael Shuster Search for more papers by this author , Jasmeet SoarJasmeet Soar Search for more papers by this author , Kjetil SundeKjetil Sunde Search for more papers by this author , Andrew H. TraversAndrew H. Travers Search for more papers by this author , Jonathan WyllieJonathan Wyllie Search for more papers by this author and David ZidemanDavid Zideman Search for more papers by this author Originally published19 Oct 2010https://doi.org/10.1161/CIRCULATIONAHA.110.970897Circulation. 2010;122:S250–S275Toward International Consensus on ScienceThe International Liaison Committee on Resuscitation (ILCOR) was founded on November 22, 1992, and currently includes representatives from the American Heart Association (AHA), the European Resuscitation Council (ERC), the Heart and Stroke Foundation of Canada (HSFC), the Australian and New Zealand Committee on Resuscitation (ANZCOR), Resuscitation Council of Southern Africa (RCSA), the InterAmerican Heart Foundation (IAHF), and the Resuscitation Council of Asia (RCA). Its mission is to identify and review international science and knowledge relevant to cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) and when there is consensus to offer treatment recommendations. Emergency cardiovascular care includes all responses necessary to treat sudden life-threatening events affecting the cardiovascular and respiratory systems, with a particular focus on sudden cardiac arrest.In 1999, the AHA hosted the first ILCOR conference to evaluate resuscitation science and develop common resuscitation guidelines. The conference recommendations were published in the International Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.1 Since 2000, researchers from the ILCOR member councils have evaluated resuscitation science in 5-year cycles. The conclusions and recommendations of the 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations were published at the end of 2005.2,3 The most recent International Consensus Conference was held in Dallas in February 2010, and this publication contains the consensus science statements and treatment recommendations developed with input from the invited participants.The goal of every resuscitation organization and resuscitation expert is to prevent premature cardiovascular death. When cardiac arrest or life-threatening emergencies occur, prompt and skillful response can make the difference between life and death and between intact survival and debilitation. This document summarizes the 2010 evidence evaluation of published science about the recognition and response to sudden life-threatening events, particularly sudden cardiac arrest and periarrest events in victims of all ages. The broad range and number of topics reviewed necessitated succinctness in the consensus science statements and brevity in treatment recommendations. This supplement is not a comprehensive review of every aspect of resuscitation medicine; not all topics reviewed in 2005 were reviewed in 2010. This executive summary highlights the evidence evaluation and treatment recommendations of the 2010 evidence evaluation process. More detailed information is available in other parts of this publication.Evidence Evaluation ProcessTo begin the current evidence evaluation process, ILCOR representatives established 6 task forces: basic life support (BLS); advanced life support (ALS); acute coronary syndromes (ACS); pediatric life support; neonatal life support; and education, implementation, and teams (EIT). Separate writing groups were formed to coordinate evidence evaluation for defibrillation and mechanical devices because these overlapped with both BLS and ALS. Each task force identified topics requiring evidence evaluation and invited international experts to review them. To ensure a consistent and thorough approach, a worksheet template was created with step-by-step directions to help the experts document their literature reviews, evaluate studies, determine levels of evidence (Table), and develop treatment recommendations (see Part 3: Evidence Evaluation Process).4 When possible, 2 expert reviewers were invited to perform independent evaluations for each topic. The worksheet authors submitted their search strategies to 1 of 3 worksheet review experts. The lead evidence evaluation expert also reviewed all worksheets and assisted the worksheet authors in ensuring consistency and quality in the evidence evaluation. This process is described in detail in Part 3.4 In conjunction with the International First Aid Science Advisory Board, the AHA established an additional task force to review evidence on first aid. This topic is summarized in Part 13. The evidence review followed the same process but was not part of the formal ILCOR review.Table. Levels of EvidenceC2010 Levels of Evidence for Studies of Therapeutic Interventions LOE 1: Randomized controlled trials (RCTs) (or meta-analyses of RCTs) LOE 2: Studies using concurrent controls without true randomization (eg, “pseudo”-randomized) LOE 3: Studies using retrospective controls LOE 4: Studies without a control group (eg, case series) LOE 5: Studies not directly related to the specific patient/population (eg, different patient/population, animal models, mechanical models, etc)C2010 Levels of Evidence for Prognostic Studies LOE P1: Inception (prospective) cohort studies (or meta-analyses of inception cohort studies), or validation of Clinical Decision Rule (CDR) LOE P2: Follow-up of untreated control groups in RCTs (or meta-analyses of follow-up studies), or derivation of CDR, or validated on split-sample only LOE P3: Retrospective cohort studies LOE P4: Case series LOE P5: Studies not directly related to the specific patient/population (eg, different patient/population, animal models, mechanical models, etc)C2010 Levels of Evidence for Diagnostic Studies LOE D1: Validating cohort studies (or meta-analyses of validating cohort studies) or validation of Clinical Decision Rule (CDR) LOE D2: Exploratory cohort study (or meta-analyses of follow-up studies), or derivation of CDR, or a CDR validated on a split-sample only LOE D3: Diagnostic case-control study LOE D4: Study of diagnostic yield (no reference standard) LOE D5: Studies not directly related to the specific patient/population (eg, different patient/population, animal models, mechanical models, etc)The evidence evaluation process from 2005–2010 initially involved 509 worksheet authors with 569 worksheets. Some of the worksheets were merged while in other cases there was no new evidence and the worksheets/topics were deleted. The 2010 International Consensus Conference in February, 2010 involved 313 experts from 30 countries. A final total of 277 specific resuscitation questions, each in standard PICO (Population, Intervention, Comparison, Outcome) format, were considered by 356 worksheet authors who reviewed thousands of relevant, peer-reviewed publications. Many of these worksheets were presented and discussed at monthly or semimonthly task force international web conferences (ie, “webinars” that involved conference calls with simultaneous internet conferencing). Beginning in May 2009 the evidence review and summary portions of the evidence evaluation worksheets, with worksheet author conflict of interest (COI) statements, were posted on the ILCOR Web site (www.ilcor.org). Journal advertisements and emails invited public comment. Persons who submitted comments were required to indicate their potential conflicts of interest. Public comments and potential conflicts of interest were sent to the appropriate ILCOR task force chair and worksheet author for consideration.To provide the widest possible dissemination of the science reviews performed for the 2010 International Consensus Conference, the worksheets prepared for the conference are linked from this document and can be accessed by clicking on the superscript worksheet numbers (each begins with a letter, typically a 3-letter abbreviation) located adjacent to headings.During the 2010 Consensus Conference, wireless Internet access was available to all conference participants to facilitate real-time verification of the literature. Expert reviewers presented summaries of their evidence evaluation in plenary and concurrent sessions. Presenters and participants then debated the evidence, conclusions, and draft summary statements. The ILCOR task forces met daily during the conference to discuss and debate the experts' recommendations and develop interim consensus science statements. Each science statement summarized the experts' interpretation of all relevant data on a specific topic, and included consensus draft treatment recommendations. The wording of science statements and treatment recommendations was revised after further review by ILCOR member organizations and the editorial board. This format ensures that the final document represents a truly international consensus process.At the time of submission this document represented the state-of-the-art science of resuscitation medicine. With the permission of the relevant journal editors, several papers were circulated among task force members if they had been accepted for publication in peer-reviewed journals but had not yet been published. These peer-reviewed and accepted manuscripts were included in the consensus statements.This manuscript was ultimately approved by all ILCOR member organizations and an international editorial board (listed on the title page of this supplement). Reviewers solicited by the editor of Circulation and the AHA Science Advisory and Coordinating Committee performed parallel peer reviews of this document before it was accepted for publication. This document is being published online simultaneously by Circulation and Resuscitation, although the version in the latter publication does not include the section on first aid.Management of Potential Conflicts of InterestIn order to ensure the evidence evaluation process was free from commercial bias, extensive conflict of interest (COI) management principles were instituted immediately following the completion of the 2005 Consensus on Science and Treatment Recommendations (CoSTR), concurrent with the start of the 2010 CoSTR process. All of the participants were governed by the COI management principles regardless of their role in the CoSTR process. COI disclosure was required from all participants and was updated annually or when changes occurred. Commercial relationships were considered at every stage of the evidence evaluation process and, depending on the nature of the relationship and their role in the evidence evaluation process, participants were restricted from some activities (ie, leading, voting, deciding, writing, discussing) that directly or indirectly related to that commercial interest. While the focus of the process was the evaluation of the scientific evidence, attention was given to potential COI throughout the CoSTR process.5–7 This policy is described in detail in Part 4: “Management of Potential Conflicts of Interest.”8Applying Science to Improve SurvivalFrom Consensus on Science to GuidelinesThis document presents international consensus statements that summarize the science of resuscitation and, wherever possible, treatment recommendations. ILCOR member organizations will subsequently publish resuscitation guidelines that are consistent with the science in this consensus document, but the organizations will also take into account geographic, economic, and system differences in practice; availability of medical devices and drugs (eg, not all devices and drugs reviewed in this publication are available and approved for use in all countries); and ease or difficulty of training. All ILCOR member organizations are committed to minimizing international differences in resuscitation practice and optimizing the effectiveness of resuscitation practice, instructional methods, teaching aids, training networks and outcomes (see Part 2: “ILCOR Collaboration”).The recommendations of the 2010 International Consensus Conference confirm the safety and effectiveness of current approaches, acknowledge other approaches as ineffective, and introduce new treatments resulting from evidence-based evaluation. New and revised treatment recommendations do not imply that clinical care that involves the use of previously published guidelines is either unsafe or ineffective. Implications for education and retention were also considered when developing the final treatment recommendations.Ischemic heart disease is the leading cause of death in the world.9,10 In addition, many newly born infants die worldwide as the result of respiratory distress immediately after birth. However, most out-of-hospital victims die without receiving the interventions described in this publication.The actions linking the adult victim of sudden cardiac arrest with survival are called the adult Chain of Survival. The links in the Chain of Survival used by many resuscitation councils include prevention of the arrest, early recognition of the emergency and activation of the emergency medical services (EMS) system, early and high-quality CPR, early defibrillation, rapid ALS, and postresuscitation care. The links in the infant and child Chain of Survival include prevention of conditions leading to cardiopulmonary arrest, early and high-quality CPR, early activation of the EMS system, and early ALS.The most important determinant of survival from sudden cardiac arrest is the presence of a trained lay rescuer who is ready, willing, and able to act. Although some ALS techniques improve survival,11,12 these improvements are usually less significant than the increase in survival rates that can result from higher rates of lay rescuer (bystander) CPR and establishment of automated external defibrillation programs in the community.13–17 Thus, our greatest challenges remain the education of the lay rescuer and understanding and overcoming the barriers that prevent even trained rescuers from performing high-quality CPR. We must increase the effectiveness and efficiency of instruction, improve skills retention, and reduce barriers to action for both basic and ALS providers. Similarly, the placement and use of automated external defibrillators (AEDs) in the community should be encouraged to enable defibrillation within the first minutes after a ventricular fibrillation (VF) sudden cardiac arrest.The Universal AlgorithmSeveral of the new treatment recommendations cited in this document are included in the updated ILCOR Universal Cardiac Arrest Algorithm (Figure). This algorithm is intended to apply to attempted resuscitation of infant, child, and adult victims of cardiac arrest (excluding newly borns). Every effort has been made to keep this algorithm simple yet make it applicable to treatment of cardiac arrest victims of all ages and in most circumstances. Modification will be required in some situations, and these exceptions are highlighted elsewhere in this document. Each resuscitation organization has based its guidelines on this ILCOR algorithm, although there will be regional modifications.Download figureDownload PowerPointFigure. The universal algorithm.Rescuers begin CPR if the adult victim is unresponsive with absent or abnormal breathing, such as an occasional gasp. A single compression-ventilation ratio of 30:2 is used for the lone lay rescuer of an infant, child, or adult victim (excluding newly borns). This single ratio is designed to simplify teaching, promote skills retention, increase the number of compressions given, and decrease interruptions in compressions. The most significant adult BLS change in this document is a recommendation for a CAB (compressions, airway, breathing) sequence instead of an ABC (airway, breathing, compressions) sequence to minimize delay to initiation of compressions and resuscitation. In other words, rescuers of adult victims should begin resuscitation with compressions rather than opening the airway and delivery of breaths.Once a defibrillator is attached, if a shockable rhythm is confirmed, a single shock is delivered. Irrespective of the resultant rhythm, CPR starting with chest compressions should resume immediately after each shock to minimize the “no-flow” time (ie, time during which compressions are not delivered, for example, during rhythm analysis). ALS interventions are outlined in a box at the center of the algorithm. Once an advanced airway (tracheal tube or supraglottic airway) has been inserted, rescuers should provide continuous chest compressions (without pauses for ventilations) and ventilations at a regular rate (avoiding excessive ventilation).The 2005 International Consensus on Science emphasized the importance of minimal interruption of chest compressions because 2005 evidence documented the frequency of interruptions in chest compressions during both in- and out-of-hospital CPR and the adverse effects of such interruptions in attaining return of spontaneous circulation (ROSC).18–20 In 2010, experts agree that rescuers should be taught to adhere to all four metrics of CPR: adequate rate, adequate depth, allowing full chest recoil after each compression and minimizing interruptions (eg, hands off time) in compressions.Most Significant Developments in Resuscitation From 2005 to 2010Although resuscitation practices are usually studied as single interventions, they are actually performed as a large sequence of actions, each with its own timing and quality of performance. It may be difficult or impossible to assess the contribution of any one action (energy level for defibrillation, airway maneuver, drug) on the most important outcomes, such as neurologically intact survival to discharge. In fact, it is likely that it is the combination of actions, each performed correctly, in time and in order, that results in optimal survival and function. A few studies give insight into this necessary shift from studying of changes in individual actions (point improvements) to studying the effects of changing the entire sequence of actions (flow improvement).21,22The compression-ventilation ratio was one of the most controversial topics of the 2005 International Consensus Conference. The experts began the 2005 conference acknowledging that rates of survival from cardiac arrest to hospital discharge were low, averaging ≤6% internationally,23,24 and that survival rates had not increased substantially in recent years. That observation led to the 2005 change to a universal compression-ventilation ratio for all lone rescuers of victims of all ages and to an emphasis on the importance of CPR quality throughout the 2005 Consensus on CPR and ECC Science With Treatment Recommendations (CoSTR) document and subsequent ILCOR member council guidelines.25Resuscitation outcomes vary considerably among regions26,27 In recent studies the outcome from cardiac arrest, particularly from shockable rhythms, is improved.28–33 Moreover, there is an association between implementation of new resuscitation guidelines and improved outcome.31,33 However, there is also evidence that new guidelines can take from 1.5 to 4 years to implement.34,35There have been many developments in resuscitation science since 2005 and these are highlighted below.Factors Affecting Lay Rescuer CPR PerformanceDuring the past 5 years, there has been an effort to simplify CPR recommendations and emphasize the importance of high-quality CPR. Large observational studies from investigators in member countries of the RCA, the newest member of ILCOR,36–39 and other studies40,41 have provided significant data about the effects of bystander CPR.CPR QualityStrategies to reduce the interval between stopping chest compressions and delivery of a shock (the preshock pause) will improve the chances of shock success.42,43 These data are driving major changes in training of resuscitation teams. Data downloaded from CPR-sensing and feedback-enabled defibrillators can be used to debrief resuscitation teams and improve CPR quality.44In-Hospital CPR RegistriesThe National Registry of CPR (NRCPR) and other registries are providing valuable information about the epidemiology and outcomes of in-hospital resuscitation in adults and children.45–52Insufficient Evidence on Devices and ALS DrugsMany devices remain under investigation, and at the time of the 2010 Consensus Conference there was insufficient evidence to recommend for or against the use of any mechanical devices. There are still no data showing that any drugs improve long-term outcome after cardiac arrest.21 Clearly further information is needed.Importance of Post–Cardiac Arrest CareIt is now clear that organized post–cardiac arrest care with emphasis on protocols for optimizing cardiovascular and neurologic care, including therapeutic hypothermia, can improve survival to hospital discharge among victims who achieve ROSC after cardiac arrest.22,53,54 Although it is not yet possible to determine the individual effect of many of these therapies, it is clear that this “bundle of care” can improve outcome. Therapeutic hypothermia has been shown independently to improve outcome after adult witnessed out-of-hospital VF cardiac arrest11,12 and after neonatal hypoxic-ischemic insult. Since 2005, 2 nonrandomized studies with concurrent controls indicated possible benefit of hypothermia after cardiac arrest from other initial rhythms in- and out-of-hospital,55,56 and other studies with historic controls have shown benefit for therapeutic hypothermia after out-of-hospital all-rhythm cardiac arrests in adults.22,57–60Studies of newborns with birth asphyxia61,62 showed that therapeutic hypothermia (33.5°C to 34.5°C) up to 72 hours after resuscitation has an acceptable safety profile and was associated with better survival and long term neurological outcome. Retrospective studies of children following cardiac arrest failed to demonstrate benefit of therapeutic hypothermia, but a well-designed multicenter prospective randomized trial is in progress.Many studies in recent years have attempted to identify comatose post–cardiac arrest patients who have no prospects of good neurologic recovery.63 It is now recognized that the use of therapeutic hypothermia invalidates the prognostication decision criteria that were established before hypothermia therapy was implemented: recent studies have documented occasional good outcomes in patients who would previously have met criteria predicting poor outcome (Cerebral Performance Category 3, 4, or 5).64,65Education and Implementation, Including RetrainingBasic and advanced life support knowledge and skills can deteriorate in as little as 3 to 6 months. Quality of education, frequent assessments and, when needed, refresher training are recommended to maintain resuscitation knowledge and skills.Summary of the 2010 ILCOR Consensus on CPR and ECC Science With Treatment RecommendationsAdult BLSThe 2010 International Consensus Conference addressed many questions related to the performance of BLS. These have been grouped into (1) epidemiology and recognition of cardiac arrest, (2) chest compressions, (3) airway and ventilation, (4) compression-ventilation sequence, (5) special situations, (6) EMS system, and (7) risks to the victim. Defibrillation is discussed separately in Part 6 because it is both a basic and an ALS skill.There have been several important advances in the science of resuscitation since the 2005 ILCOR review. The following is a summary of the most important evidence-based recommendations for performance of BLS: Lay rescuers begin CPR if the adult victim is unresponsive and not breathing normally (ignoring occasional gasps) without assessing the victim's pulse.Following initial assessment, rescuers begin CPR with chest compressions rather than opening the airway and delivering rescue breathing.All rescuers, trained or not, should provide chest compressions to victims of cardiac arrest. A strong emphasis on delivering high-quality chest compressions remains essential: push hard to a depth of at least 2 inches (5 cm) at a rate of at least 100 compressions per minute, allow full chest recoil after each compression, and minimize interruptions in chest compressions.Trained rescuers should also provide ventilations with a compression-ventilation ratio of 30:2.EMS dispatchers should provide telephone instruction in chest compression-only CPR for untrained rescuers.Epidemiology and Recognition of Cardiac ArrestEarly recognition is a key step in initiating early treatment of cardiac arrest; this recognition requires identification of the most accurate method of determining cardiac arrest. In general rescuers should begin CPR if an adult is unresponsive and not breathing normally (disregarding occasional gasps). Healthcare providers cannot reliably determine the presence or absence of a pulse, so CPR should not be delayed if a pulse is not immediately found in the unresponsive adult victim who is not breathing normally. Lay rescuers cannot reliably determine the cause of an arrest, so it is not realistic to expect them to alter the response sequence to the likely etiology of each arrest.Chest CompressionsSeveral components of chest compressions can alter effectiveness: hand position, position of the rescuer, position of the victim, compression depth, chest recoil, and duty cycle (see definition, below). Compression depth should at least be 2 inches (5 cm). Evidence for these techniques was reviewed in an attempt to define the optimal method.Compressions Only and Compressions Plus VentilationsAll rescuers should perform chest compressions for all patients in cardiac arrest. Chest compressions alone are recommended for untrained laypersons responding to victims of cardiac arrest. Performing chest compressions alone is reasonable for trained laypersons if they are incapable of delivering airway and breathing maneuvers to cardiac arrest victims. Providing chest compressions with ventilations is reasonable for trained laypersons who are capable of giving CPR with ventilations to cardiac arrest victims.Professional rescuers should provide chest compressions with ventilations for cardiac arrest victims. There is insufficient evidence to support or refute the effectiveness of the combination of chest compressions plus airway opening and oxygen inflation (compared with conventional CPR) by professional rescuers during the first few minutes of resuscitation from cardiac arrest.Airway and VentilationThe best method of obtaining an open airway and the optimum frequency and volume of artificial ventilation were reviewed. The recommendations are unchanged from 2005.Compression-Ventilation SequenceIn the 2005 International Consensus Conference recommendations, the recommended sequence of CPR actions was: airway, breathing, and circulation/chest compressions (A" @default.
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W4365364786 title "Part 1: Executive Summary" @default.
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