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2005 Changes to the American Heart Association Guidelines For N E WS N E WS Pharmacotherapy Update LETTER Pharmacotherapyfrom the DepartmentUpdate of Pharmacy LETTER fromVolume the IX,Department No. II March/April of Pharmacy 2006 Mandy C. Leonard, Pharm.D., BCPS Assistant Director, Drug Information Service 2005 Changes to the American Heart Association Editor Guidelines for Cardiopulmonary Resuscitation Meghan K. Lehmann, Pharm.D., BCPS by Heather Bockheim, Pharm.D. Drug Information Specialist Editor The concept of resuscitation was first documented in 1740, when the Paris Academy of Sciences recommended mouth-to-mouth resuscitation for drowning Dana L. Travis, R.Ph. victims.1 Almost 200 years later, in 1903, Dr. George W. Crile, co-founder of Drug Information Pharmacist Editor the Cleveland Clinic, reported the first successful use of external chest compres- sions in human resuscitation.1 In 1957, the United States military adopted the David A. White, B.S., R.Ph. use of mouth-to-mouth resuscitation to aid in the revival of unresponsive Restricted Drug Pharmacist patients.1 Finally, in 1960, closed chest cardiopulmonary resuscitation (CPR) Associate Editor was developed. Shortly thereafter, the American Heart Association (AHA) Marcia J. Wyman, Pharm.D. began developing training programs for both physicians and the public (See 1 Drug Information Pharmacist Figure 1). Associate Editor In the United States, sudden cardiac arrest (SCA) accounts for 250,000 out-of- Amy T. Sekel, Pharm.D. 2 Drug Information Pharmacist hospital deaths each year. Despite enormous labors to encourage public aware- AssociateIn this IssueEditor ness and education, cardiopulmonary arrest remains a significant public health challenge worldwide. The survival rate for out-of-hospital SCA remains dismal David Kvancz, M.S., R.Ph., FASHP with 94% of victims dying prior to hospital arrival worldwide.2 Chief Pharmacy Officer Morton Goldman, Pharm.D., BCPS The revised AHA guidelines for CPR and emergency cardiovascular care 3 Director, Pharmacotherapy Services (ECC) were updated and published in December 2005. The recommendations In This Issue: are based on the review of evidence from the 2005 International Consensus 4 • AHA Guidelines for CPR Conference on CPR and ECC. The International Liaison Committee on Resus- citation (ILCOR) was formed in 1993 and is composed of representatives of • Orlistat for OTC Status multiple resuscitation councils from around the world.3 ILCOR was charged • Formulary Update with the responsibility of reviewing international resuscitation literature and lending their expertise about CPR and ECC in order to create consensus treat- ment recommendations.3 The culmination of these efforts are the 2005 Adult Drug Information Service AHA Guidelines for CPR and ECC. (216) 444-6456, option #1 Comprehensive information about The focus of this paper is to highlight the major changes to the 2005 Adult medications, biologics, nutrients, AHA Guidelines for CPR and ECC, but is not all inclusive. This review will and drug therapy include the following changes to the Guidelines: 1) a renewed emphasis on the delivery of effective chest compressions, 2) modified treatment of ventricular Formulary Information fibrillation/pulseless ventricular tachycardia (VF/VT), and 3) modified treat- ment of asystole/pulseless electrical activity.5 The reader is encouraged to refer Medication Inservices to the Guidelines for a detailed review of all aspects of CPR and ECC. The evidence classification system utilized is the same as that used by the American Heart Association-American College of Cardiology collaboration on Department of Pharmacy/Hb03, Drug Information Center, 9500 Euclid Avenue, Cleveland, Ohio 44195 (216)444-6456 Department of Pharmacy/Hb03, Drug Information Center, 9500 Euclid Avenue, Cleveland, Ohio 44195 (216)444-6456 THE CLEVELAND CLINIC FOUNDATION THE CLEVELAND CLINIC FOUNDATION Figure 1: Resuscitation Timeline1 1740 1903 1957 1960 1963 1972 1981 Paris Academy Dr. George W. United States CPR was Dr. Leonard Dr. Leonard Dispatcher- of Sciences: Crile reports military developed: Scherlis Cobb holds assisted CPR mouth-to- successful use adopts AHA be- establishes first mass mouth resusci- of external mouth-to- comes fore- the AHA’s citizen CPR tation for chest compres- mouth runner of CPR training in drowning sions resuscitation CPR training committee Seattle, WA victims for public evidence-based guidelines (Table 1).3 Class I recommendations component of CPR that deliver some blood flow to vital have high-level prospective studies to support the treatment and organs such as the heart and brain. By optimizing chest the risk substantially outweighs the harm.3 Class IIa recom- compression technique and minimizing interruptions, mendations are those in which most of the evidence supports more blood may be delivered to vital organs, providing a the intervention, and the treatment is considered acceptable and better chance for survival.5 Previous literature has demon- useful.3 Class IIb recommendations are those for which the strated that the quality of chest compressions, even when intervention has only been documented as beneficial in the delivered by trained emergency medical services person- short-term, or when positive outcomes were reported with nel (EMS), may be less than optimal.5 In one study of lower levels of evidence.3 Class IIb recommendations are fur- EMS personnel with an average of 6.4 ± 4.2 years of ex- ther delineated as 1) optional or 2) recommended by the panel perience, it was found that incomplete chest wall decom- despite the absence of high-level supporting evidence.3 Op- pression was observed at some point during CPR in 6 of tional recommendations are identified as “can be considered” or 13 (46%) cardiac arrests.6 It is hoped that the renewed “may be useful.”3 Class III recommendations are treatments emphasis on the delivery of effective chest compressions that should not be administered as they may be harmful.3 The with minimal interruptions will encourage retention of Guidelines cannot recommend for or against interventions la- basic cardiac life support sequence by rescuers. beled as Class Indeterminate.3 VF/VT Due to the low survival rate from out-of-hospital cardiac arrest, few resuscitation trials have the power to detect a difference in The second change to the 2005 Guidelines is to the algo- long-term outcomes among study populations.4 When investi- rithm for the treatment of ventricular fibrillation/pulseless gators attempt to conduct research involving victims of SCA, ventricular tachycardia (VF/VT) (See Figure 2). Ventricu- multiple other considerations and constraints may affect the lar fibrillation is the presenting arrhythmia in 60 to 80% of design and successful completion of studies with the primary SCA, with a survival rate of 4 to 33%. The major change outcome being that of “identification of interventions that im- to the VF/VT algorithm is the defibrillation and chest prove neurologically intact survival to hospital discharge.”3 compression sequence. The current recommendation for Subsequently, there are few Class I recommendations repre- patients with a shockable rhythm, VF/VT, is to deliver sented in the 2005 Guidelines and thus many recommendations 1 shock followed immediately by a period of CPR, begin- were made by consensus, taking into consideration the clinical ning with 5 cycles of chest compressions lasting 2 minutes and laboratory evidence available for evaluation.3 in duration (Class IIa).7 This is opposed to the previous recommendation of delivering 3 stacked shocks in se- Effective Chest Compressions quence. This new recommendation was made in light of a transition to the utilization of biphasic defibrillators that The first major change to the 2005 Guidelines is a stronger em- have a much higher rate of first-shock dysrhythmia termi- phasis on the importance of delivering effective chest compres- nation.8 In addition, rhythm analysis by currently avail- sions (Class I). Rescuers should use a chest compression to able automated external defibrillators may carry a delay of ventilation ratio of 30:2 for all adult victims.6 The rescuer up to 37 seconds before delivery of the first post- should compress the chest, pushing hard and fast, to a depth of compression shock.5 This delay may jeopardize the small about 1½ to 2 inches.6 The chest should be allowed to recoil but critical amount of oxygen that is delivered to the myo- back to the normal position after each compression, thereby cardium and brain produced during chest compressions. allowing blood to fill the heart.5 Chest compressions should be This change in sequence also recognizes that even when a delivered at a rate of 100 per minute.6 An effort should be shock terminates VF, many patients remain in a non- made to minimize interruptions in the delivery of effective perfusing rhythm. Delivering chest compressions after a chest compressions.6 Effective chest compressions are the successful shock allows time for the heart to return to a Table 1. Classification of Recommendations Class I Class IIa Class IIb Class III Class Indeterminate Benefit >>> Risk Benefit >> Risk Benefit � Risk Risk � Benefit High-level pro- Weight of evidence Lower level of evi- Research is ongoing spective evidence supports the inter- dence to support the vention intervention, or short-term benefits documented Intervention Intervention consid- Intervention may be Intervention should Cannot recommend should be per- ered acceptable considered and may not be performed; for or against the formed and useful be useful may be harmful intervention As adapted from: Circulation 2005;112:IV-1-IV-5. normal perfusing rhythm, while the chest compressions deliver push over 5 to 20 minutes may be administered for tor- oxygen to the myocardium.5 According to the AHA, there is sades de pointes associated with a long QT interval no evidence that performing chest compressions subsequent to (Class IIa for torsades). defibrillation will induce a recurrence of VF.5 Asystole/Pulseless Electrical Activity When treating a patient with VF/VT, the rescuer should con- tinue to provide 5 cycles of CPR for approximately 2 minutes, Asystole and pulseless electrical activity (PEA) account then evaluate for rhythm and/or presence or absence of pulse.
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