NEW CPR GUIDELINES

The Norwegian Resuscitation Council has released revised guidelines for CPR, and presented them at the Scandinavian conference for emergency medicine, SAM 16. These recommendations might differ from international recommendations. Click image or “more” for a quick English translation and run-through of the changes listed in the slide:

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  1. Always give a shock as soon as a defibrillator is available, don’t give a round of compressions first.
    The recommendation used to be initial defib in witnessed arrest where a defibrillator was immediately available. Now, a shock is recommended as soon as you get your hands on a defibrillator and have it ready to go.
  2. With initial VF/VT, wait with drugs until you’ve done 4 mins of Advanced CPR.
    This follows the trend that recognises that early and goood CPR is what really makes a difference in survival. Drugs come in as an adjuct once good CPR is up and running.
  3. Intubation only by anaesthetic personnel with regular training
    There are too many failed intubations, and intubations necessitating long pauses in CPR with untrained personnel. In Norway, only anaesthetic personnel currently has this regular training.
  4. Mechanical CPR is an alternative to standard manual CPR
    LUCAS and friends are great for transportation, freeing up hands, and for facilitating procedures like PCI. This has been known for some years.
  5. Temperature range for therapeutic hypothermia is now 32-36°C
    Finally recognising the TTM trial.
  6. Prehospital initiation of therapeutic hypothermia is not recommended
    Trials so far have been a let-down.
  7. In pregnant patients in cardiac arrest, perimortem caesarian should be initiated after 4 mins of unsuccessful CPR.
    Yes!
  8. Transport to facility that can perform emergent PCI should be considered in selected pts in refractory VT/VF
    This has been done for quite a long time, nice to finally have it in the guidelines.
  9. ECMO can be considered in selected patients
    Finally, also in the guidelines…
  10. Traumatic arrests should be treated as actively and aggressively as medical arrests
    Yes, but resuscitation of traumatic arrests shouldn’t follow the medical CPR algorithm! It’s a different entity! Read up on traumatic arrest algorithm here
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4 Responses to NEW CPR GUIDELINES

  1. Interested in the ‘only anaes personnel’ to intubate – appreciate there are differences between countries and prehospital skill mix

    So…EM also ‘allowed’ to intubate? I presume the above refers to both OOHCA and those reaching ED?

    And for non-anaes personnel in prehospital, are you using 2nd gen LMAs such as AirQ or iGel which allow staged airway – initial LMA then passage of ETT in ED via fibreoptic scope, without interrupting CPR (manual or LUCAS)

    Genuinely curious…

    • Thomas D says:

      Hi Tim, thanks for your comments! I knew that part would spark some debate – but in Norway we don’t have emergency medicine as a specialty yet (although it will probably be started within the next couple of years).

      And even in our neighbouring countries, emergency medicine is in its infancy – so their area of practice is still very much a work in progress, and they do not yet do advanced airway management. It’s a very energetic and dedicated crowd, so they will surely continue to expand on their area of practice. But in Norway, for now, only anaesthesia are trained in intubation and airway management. And in-hospital, no-one but anaesthesia would ever want nor consider to intubate a patient.

      Having said that, anaesthetic nurses would also be considered to be competent in intubation, and therefore the Norwegian guidelines refer to anaesthetic personnel, not just anaesthetists.

      The comment on intubation in the Norwegian setting is thus aimed at prehospital personnel, where, previously, ambos have been intubating cardiac arrest patients. Many of them were good, but I think a lack of consistent training and re-training led the system as a whole to have far too many failed intubations. And as many other systems around the world, they have now largely moved to using LMAs, and the guidelines are just reflecting that change.

      Our service use iGels, but that will differ around the country. I agree that 2nd gen LMAs that can be used as conduits for intubation makes sense. These are also usually easier and better to place as well.

      Mostly they will be removed and the patient intubated using direct laryngoscopy without interrupting CPR, but we should probably use more LMA conduits and fibreoptics.

  2. Katrin Hruska says:

    Nice summary! Could you also highlight if there are any discrepancies compared to the ERC guidelines?

    • Thomas D says:

      I’ll only go into the points mentioned in this slide and how they differ from ECR guidelines from 2015. I see the Norwegian guideline as continuing the trends from the ECR guidelines and in some areas taking them a bit further. All guidelines are work in progress, so it’s mostly a natural progression.

      1. The move to give a shock immediately, is also present in ECR, but this focus seems even clearer and stronger in these Norwegian guidelines, emphasising early shock.
      2.ECR guidelines also downplay the role of drugs, but an actual recommendation to wait until the first loop of CPR is done, is new. Also, Norwegian loops are of 3 mins duration as opposed to 2 mins in ECR.
      3. Intubation. ECR also voices concern over the high incidence of failed intubations in paramedic settings, but say the strategy will depend on training etc. ECR: “Intubation should be used only when trained personnel are available to carry out the procedure with a high level of skill and confidence”. In Norway, the new guidelines reflect this, and place intubation with the only specialty that does advanced airway management with any regularity. This will of course vary from country to country, system to system.
      4. LUCAS is now an established alternative to manual CPR. ECR says it can be considered in special circumstances.
      5. Post-resuscitation care with TTM of 32-36°C is in line with the ECR guidelines.
      6. Not recommending pre-hospital cooling is in agreement with ECR.
      7. Post-mortem caesarean, started within 4 mins, is in agreement with ECR.
      8. There is an emphasis on urgent PCI also in ECR.
      9. ECMO weak recommendations are much the same.
      10. In traumatic arrest, ECR says ” Immediate resuscitative efforts in TCA focus on simultaneous treatment of reversible causes, which takes priority over chest compressions”. ECR also recommends the traumatic cardiac arrest algorithm we linked to above.

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