Resuscitation 81 (2010) 1305–1352 Contents lists available at ScienceDirect Resuscitation journal homepage: www.elsevier.com/locate/resuscitation European Resuscitation Council Guidelines for Resuscitation 2010 Section 4. Adult advanced life support Charles D. Deakin a,1, Jerry P. Nolan b,∗,1, Jasmeet Soar c, Kjetil Sunde d, Rudolph W. Koster e, Gary B. Smith f, Gavin D. Perkins f a Cardiothoracic Anaesthesia, Southampton General Hospital, Southampton, UK b Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK c Anaesthesia and Intensive Care Medicine, Southmead Hospital, Bristol, UK d Surgical Intensive Care Unit, Oslo University Hospital Ulleval, Oslo, Norway e Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands f Critical Care and Resuscitation, University of Warwick, Warwick Medical School, Warwick, UK Summary of changes since 2005 Guidelines then every 3–5 min (during alternate cycles of CPR). Amiodarone 300 mg is also given after the third shock. • The most important changes in the 2010 European Resuscitation Atropine is no longer recommended for routine use in asystole or Council Advanced Life Support (ALS) Guidelines include: pulseless electrical activity. • Reduced emphasis on early tracheal intubation unless achieved • Increased emphasis on the importance of minimally interrupted by highly skilled individuals with minimal interruption to chest compressions. high-quality chest compressions throughout any ALS interven- • tion: chest compressions are paused briefly only to enable specific Increased emphasis on the use of capnography to confirm and interventions. continually monitor tracheal tube placement, quality of CPR and • Increased emphasis on the use of ‘track and trigger systems’ to to provide an early indication of return of spontaneous circulation detect the deteriorating patient and enable treatment to prevent (ROSC). • The potential role of ultrasound imaging during ALS is recognised. in-hospital cardiac arrest. • • Increased awareness of the warning signs associated with the Recognition of the potential harm caused by hyperoxaemia after potential risk of sudden cardiac death out of hospital. ROSC is achieved: once ROSC has been established and the oxy- • Removal of the recommendation for a pre-specified period gen saturation of arterial blood (SaO2) can be monitored reliably of cardiopulmonary resuscitation (CPR) before out-of-hospital (by pulse oximetry and/or arterial blood gas analysis), inspired oxygen is titrated to achieve a SaO2 of 94–98%. defibrillation following cardiac arrest unwitnessed by the emer- • gency medical services (EMS). Much greater detail and emphasis on the treatment of the post- • cardiac arrest syndrome. Continuation of chest compressions while a defibrillator is • charged—this will minimise the preshock pause. Recognition that implementation of a comprehensive, structured • The role of the precordial thump is de-emphasised. post-resuscitation treatment protocol may improve survival in • cardiac arrest victims after ROSC. The use of up to three quick successive (stacked) shocks for • ventricular fibrillation/pulseless ventricular tachycardia (VF/VT) Increased emphasis on the use of primary percutaneous coro- occurring in the cardiac catheterisation laboratory or in the nary intervention in appropriate, but comatose, patients with sustained ROSC after cardiac arrest. immediate post-operative period following cardiac surgery. • • Delivery of drugs via a tracheal tube is no longer Revision of the recommendation for glucose control: in adults recommended—if intravenous access cannot be achieved, with sustained ROSC after cardiac arrest, blood glucose values −1 −1 drugs should be given by the intraosseous route. >10 mmol l (>180 mg dl ) should be treated but hypogly- • caemia must be avoided. When treating VF/VT cardiac arrest, adrenaline 1 mg is given • after the third shock once chest compressions have restarted and Use of therapeutic hypothermia to include comatose sur- vivors of cardiac arrest associated initially with non-shockable rhythms as well shockable rhythms. The lower level of evi- dence for use after cardiac arrest from non-shockable rhythms is ∗ Corresponding author. acknowledged. E-mail address: [email protected] (J.P. Nolan). • Recognition that many of the accepted predictors of poor out- 1 These individuals contributed equally to this manuscript and are equal first come in comatose survivors of cardiac arrest are unreliable, co-authors. 0300-9572/$ – see front matter © 2010 European Resuscitation Council. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.resuscitation.2010.08.017 1306 C.D. Deakin et al. / Resuscitation 81 (2010) 1305–1352 especially if the patient has been treated with therapeutic In an Australian study, virtually all the improvement in the hos- hypothermia. pital cardiac arrest rate occurred during the educational phase of implementation of a medical emergency team (MET) system.45,46 4a Prevention of in-hospital cardiac arrest In studies from Australian and American hospitals with estab- lished rapid response teams, education about the specific criteria for activating their teams led to proactive ICU admission of patients Early recognition of the deteriorating patient and prevention and a reduction in the number of ward cardiac arrests.47–49 AUK of cardiac arrest is the first link in the chain of survival.1 Once study found that the number of cardiac arrest calls decreased while cardiac arrest occurs, fewer than 20% of patients suffering an in- pre-arrest calls increased after implementing a standardised edu- hospital cardiac arrest will survive to go home.2–4 Prevention of cational program in two hospitals; the intervention was associated in-hospital cardiac arrest requires staff education, monitoring of with a decrease in true arrests, and increase in initial survival after patients, recognition of patient deterioration, a system to call for cardiac arrest and survival to discharge.50,51 help and an effective response.5 The problem Monitoring and recognition of the critically ill patient Cardiac arrest in patients in unmonitored ward areas is not In general, the clinical signs of acute illness are similar what- usually a sudden unpredictable event, nor is it usually caused ever the underlying process, as they reflect failing respiratory, 6 by primary cardiac disease. These patients often have slow and cardiovascular and neurological systems. Abnormal physiology is progressive physiological deterioration, involving hypoxaemia and common on general wards,52 yet the measurement and recording hypotension that is unnoticed by staff, or is recognised but treated of important physiological observations of sick patients occurs less 7–9 poorly. Many of these patients have unmonitored arrests, and frequently than is desirable.6,8,13,16,24,53,54 3,10 the underlying cardiac arrest rhythm is usually non-shockable. To assist in the early detection of critical illness, each patient 2,4,10 Survival to hospital discharge is poor. should have a documented plan for vital signs monitoring that The records of patients who have a cardiac arrest or unan- identifies which variables need to be measured and the frequency ticipated intensive care unit (ICU) admission often contain of measurement.26 Many hospitals now use early warning scores evidence of unrecognised, or untreated, respiratory and circula- (EWS) or calling criteria to identify the need to escalate monitor- 6,8,11–16 tion problems. The ACADEMIA study showed antecedents ing, treatment, or to call for expert help.13,24,55–57 The use of these in 79% of cardiac arrests, 55% of deaths and 54% of unanticipated ICU systems has been shown to increase the frequency of patient vital 8 admissions. Early and effective treatment of seriously ill patients signs measurements.54,58,59 might prevent some cardiac arrests, deaths and unanticipated ICU These calling criteria or ‘track-and-trigger’ systems include admissions. Several studies show that up to a third of patients who single-parameter systems, multiple-parameter systems, aggregate 17–19 have a false cardiac arrest call subsequently die. weighted scoring systems or combination systems.60 The aggre- gate weighted track-and-trigger systems offer a graded escalation Nature of the deficiencies in the recognition and response of care, whereas single parameter track and trigger systems provide to patient deterioration an all-or-nothing response. Most of these systems lack robust data to suggest they have These often include: infrequent, late or incomplete vital signs acceptable accuracy for use in the roles for which they are pro- assessments; lack of knowledge of normal vital signs values; poor posed. Low sensitivity of systems means that a significant number design of vital signs charts; poor sensitivity and specificity of ‘track of patients at risk of deterioration leading to cardiac arrest are likely and trigger’ systems; failure of staff to increase monitoring or esca- to be missed.61,62 Hospitals should use a system validated for their late care, and staff workload.20–28 There is also often a failure to specific patient population to identify individuals at increased risk treat abnormalities of the patient’s airway, breathing and circula- of serious clinical deterioration, cardiac arrest, or death, both on tion, incorrect use of oxygen therapy, poor communication, lack of admission and during hospital stay. teamwork and insufficient use of treatment limitation plans.7,14,29 Alterations in physiological variables,