The first release of CPR Standards and Guidelines happened in 1975. Since that time, updates have been issued approximately every five years. It’s been five years since the current guidelines were released in 2010, and the new guidelines will be released on October 15, 2015. At that time, new recommendations will be made for all accredited training organizations to review and implement in order to comply with the International Liaison Committee on Resuscitation (ILCOR).
Who is ILCOR? I thought the American Heart Association set the standards!
The International Liaison Committee on Resuscitation (ILCOR) formed in 1992 in order to provide a forum for liaison between many resuscitation organizations worldwide. All member organizations are expected to have an accepted activity for creating resuscitation guidelines, preferably for more than one country, and to be multidisciplinary in membership.
ILCOR currently comprises representatives of:
- American Heart Association (AHA)
- European Resuscitation Council (ERC)
- Heart and Stroke Foundation of Canada (HSFC)
- Australian and New Zealand Committee on Resuscitation (ANZCOR)
- Resuscitation Councils of Southern Africa (RCSA)
- Inter American Heart Foundation (IAHF)
- Resuscitation Council of Asia (RCA)
What does the ILCOR do?
The objectives of the ILCOR are to:
- Provide a forum for discussion and for coordination of all aspects of cardiopulmonary and cerebral resuscitation worldwide.
- Foster scientific research in areas of resuscitation where there is a lack of data or where there is controversy.
- Disseminate information on training and education in resuscitation.
- Provide a mechanism for collecting, reviewing and sharing international scientific data on resuscitation.
- Produce statements on specific issues related to resuscitation that reflect international consensus.
The new recommendations and guidelines for CPR and First Aid are then compiled based on the scientific research, good – bad – or indifferent, and are compiled by the ILCOR Scientific Evidence Evaluation and Review System. The following is the written form of what that review system proposed for 2015 changes and what they most likely will or will not implement, based on science and evidence that the changes would be beneficial for prevention and resuscitation in cardiovascular and first aid emergencies.
ProTrainings is an accredited provider of science-based CPR and First Aid training and certification and adheres to the recommendations of the ILCOR and the American Heart Association in the U.S. and the ERC in the U.K.
We have compiled the list of proposed changes and the determination made by the ILCOR SEERS. We believe that though it’s not “over till it’s over,” the following questions and answers will most likely be adopted upon the official release of the new 2015 guidelines.
How will ProTrainings handle these updates?
ProTrainings and its family of CPR and First Aid certification programs will reflect these changes both in direct training and certification as well as all electronic and written documentation as soon as possible. We hope to have all changes completed before January 1st, 2016, just as we did with the 2010 guidelines.
What do I need to do as a student or an instructor/skill evaluator for ProTrainings?
Though most training organizations use these updates as an excuse to sell newly revised materials, ProTrainings is committed to being customer centric. For every affiliate instructor of ProTrainings, all changes to electronic material will be offered for update at minimal or no additional charge. We will ensure that as soon as all training programs are updated, our network of instructors will be notified, update training will be offered, instructor certifications will be updated and existing and newly certified students will be made aware of all applicable changes and renewed in an efficient and timely manner with as little burden as possible.
Okay, that’s great! But what might the changes be? I’ve seen a little bit of what the changes may reflect and a lot of nothing substantial. I can’t take the suspense any more!
Though no one, not even ProTrainings, can tell you exactly what the October 15 changes are going to be for sure, based on reliable research and pre-released information from credible sources, we’re going to share with you our speculations to help curb your curiosity appetite.
Remember, we will not know what proposed changes will actually be in the new updates until October 15, 2015, but we can at least share with you some very intelligent guesses at what the changes could be and why they did or didn’t make it into the 2015 updates.
How are you going to organize this?
We break out each of the proposed changes in the order they were presented from the ILCOR Scientific Evidence Evaluation and Review System website. Each of these proposed changes were proposed and answered in a format that can be quite complicated and confusing because of all of the scientific and statistical jargon. In this article, we attempt to scrape most of the confusion and wordiness away in order to make it as simple and understandable as possible without losing the spirit of the information.
The information is displayed as follows:
- The proposed change.
- The science and research behind the prospective change or no change.
- The final proposed suggestion whether it was due to strong science, evidence and research.
If we think that due to supportive science and study there will be minimal or no change from the current 2010 guidelines, we will state either “NO CHANGE” or “will not change” or “slight change possible,” etc.
Speculated and Proposed Basic Life Support (BLS) changes:
Analysis of rhythm during chest compression (NO CHANGE)
- Full Question: Will the new guidelines require cardiac rhythm to be analyzed during compressions?
- Consensus on Science: Due to lack of human studies and poor scientific evidence, there most likely will be no suggested change.
- Treatment Recommendation: Probably No Change For 2015.
Check for circulation during BLS (Most likely NO CHANGE)
- Full Question: Will the new guidelines promote interrupted CPR in order to check for pulses?
- Consensus on Science: Still no solid human data or scientific proof to suggest a change.
- Treatment Recommendation: Most likely no change for 2015.
Chest compression depth (Possible Slight Change)
- Full Question: Will this guideline update teach to compress the chest even deeper than the already suggested 2 inches in adult and ? depth in children?
- Consensus on Science: Science was weak in trying to determine benefits and the potential benefits didn’t outweigh the potential dangers of too deep of compression.
- Treatment Recommendation: Most likely no change for 2015.
Chest compression only CPR vs conventional CPR (NO CHANGE)
- Full Question: Will the 2015 guidelines promote that every layperson trained or untrained do compression only CPR because it’s better than traditional compression and rescue breath CPR?
- Consensus on Science: The results showed very low quality evidence (downgraded for risk of bias, indirectness, and imprecision) and therefore not enough evidence to make this change.
- Treatment Recommendation: Most likely same standards as 2010 will apply for trained and untrained lay persons.
Chest compression rate (NO APPARENT CHANGE)
- Full Question: Is the AHA going to make the compression rate faster in 2015?
- Consensus on Science: Poor scientific research, very low to no trials to prove theory of faster CPR compressions would be more beneficial than previous guidelines.
- Treatment Recommendation: CPR rate will most likely remain around 100-120 compressions per minute (CPM) as in the 2010 guidelines.
Chest wall recoil (NO CHANGE, recommends full chest recoil same as current)
Compression ventilation ratio (NO CHANGE)
- Full Question: Will the new guidelines change the compression to rescue breaths ratio?
- Consensus on Science: Low level of evidence that a change in compression and ventilation ratio would improve outcomes.
- Treatment Recommendation: Due to insufficient evidence that any other ratio would improve outcomes from sudden cardiac arrest, the 30:2 compression to breath ratio will most likely remain the same.
CPR prior to defibrillation (Possible Slight Modification)
- Full Question: Will the new guidelines encourage a longer period of CPR prior to defibrillation?
- Consensus on Science: There were studies where the intervention assessed was after a short period of chest compressions before defibrillation with a longer period of chest compressions defined as between 90 to 180 seconds before defibrillation.
- Treatment Recommendation: We believe that the 2015 guidelines will favor a short duration (30-90 seconds) of CPR prior to defibrillation. This is usually the time frame for removing clothing and preparing the patient for initial shock.
Drowning (Slight Change in Recommendation)
- Full Question: Will the recommendations change regarding how long a person is submerged and what type of water they were in (i.e. salt vs. fresh water) and how it may affect the resuscitation efforts?
- Consensus on Science: Relatively few studies reviewed adjusted for all known confounders and several studies lacked complete follow-up data.
- Treatment Recommendation: We recommend that a rescuer can use a submersion duration of 25 minutes as a guideline for a very low chance of favorable outcomes. We recommend against the use of age, water type (fresh / salt), water temperature, and witness status as factors to predict adverse outcome in adults and children submerged in water.
EMS CC only vs standard CPR (Possible Slight Change)
- Full Question: Will the new guidelines direct EMS professionals to change to compression only CPR vs. standard ventilation and compression CPR?
- Consensus on Science: The study was downgraded for risk of bias and indirectness and offered few examples or studies as best.
- Treatment Recommendation: We may see guideline changes for EMS to deliver up to three cycles of 120 seconds of 200 continuous chest compressions with interposed shocks for witnessed shockable out of hospital cardiac arrest by EMS systems. This is similar to those characterized in published studies. This is, however, a weak recommendation with very low quality of evidence.
Feedback for CPR quality (Possible Change)
- Full Question: Will the new guidelines require a real time feedback device for CPR quality?
- Consensus on Science: Not enough evidence in improved outcomes to counter the increased cost burden.
- Treatment Recommendation: It’s probable that it will not be instituted against routine implementation of CPR feedback devices in systems in which they are currently not used. In systems currently using CPR feedback devices we suggest the devices may continue to be used that there is no evidence suggesting significant harm. In making this recommendation, we place a higher value on resource allocation and cost effectiveness than widespread implementation of a technology with uncertain effectiveness.
Harm from CPR to victims not in arrest (NO CHANGE)
- Full Question: Will the new guidelines implement a new rule in regards to providing CPR accidentally to those who don’t need CPR?
- Consensus on Science: In this case, the risk of doing further harm in an unconscious non normal breathing child or adult does not outweigh the potential benefits of CPR to one who needs CPR.
- Treatment Recommendation: CPR will still be encouraged even when in doubt regarding the absolute need for full CPR as it provides more benefit for their life than no CPR at all.
Minimizing pauses in chest compressions (Possible Slight Change or Clarification)
- Full Question: Will the guidelines permit pulse checks in between sets of CPR again?
- Consensus on Science: There was not enough science that showed enough evidence to change the standard treatment.
- Treatment Recommendation: The guidelines will most likely suggest that two ventilations are delivered within 10 seconds. When airway is protected, we recommend that ventilations are delivered within 5 seconds (added for discussion) We suggest that pre-shock and post-shock pauses in chest compressions be as short as possible. For manual defibrillators, we suggest that pre-shock pauses are ?10 seconds.
Opioid overdose response education (Possible Change)
- Full Question: I heard that Naloxone is now over the counter in some states for Opiod overdoses, will it’s training be introduced in this new update?
- Consensus on Science: We did not identify any evidence to address the critical outcome of favorable neurological outcome. For the critical outcome survival to hospital discharge we have identified very low quality evidence (downgraded for risk of bias, inconsistency, indirectness and imprecision) from three observational before-and-after studies (Albert 2011 77, Maxwell 2006 89, Walley 2013).
- Treatment Recommendation: The ILCOR is suggesting offering opioid overdose response education “with or without naloxone distribution to persons at risk for opioid overdose in any setting”.
Passive ventilation techniques (Possible Change for Healthcare Professionals in field)
- Full Question: There’s been some talk about giving a patient in cardiac arrest passive oxygenation by positioning the body, opening the airway, and passive oxygen administration for chest compression-only CPR. Will that be in the new guidelines?
- Consensus on Science: Both studies on passive oxygenation during compression only CPR (COCPR) were downgraded due to risk of serious bias. Saissy, et al., studied continuous insufflation of air or oxygen (CIO) through microcannulas inserted into the inner wall of a modified intubation tube and generating a permanent positive intrathoracic pressure; endpoints were respiratory effects of the intervention compared with intermittent positive pressure ventilation; however, none of the patients in either group survived to hospital discharge.
- Treatment Recommendation: Though we don’t think it will make it into the guidelines for health care professionals, there was some suggestions that in the prehospital setting, EMS providers may consider passive ventilation using an oropharyngeal tube and oxygen delivery mask while performing continuous chest compressions. I could maybe see this only in those cases where active ventilation can not be achieved for whatever reason.
Public access AED programs (NO CHANGE)
- Full Question: Will there be any statements made in respect to more robust public access AED programs vs. reliance upon EMS?
- Consensus on Science: For “survival to one year with favorable neurological outcome” we have identified very low quality evidence (downgraded for risk of bias) from one observational trial (Cappato 2006 553) enrolling 1394 patients showing improved outcomes with public access defibrillation.
- Treatment Recommendation: Though the AHA will continue to support public access AED programs, they stated, “in making this recommendation, we place a higher value on positive clinical benefits than widespread implementation of a program with uncertain resource allocation and cost effectiveness.” In short, the current EMS program is more proven to save lives than increasing public access of AED’s by the public, and reducing EMS access.
Rhythm check timing (NO CHANGE)
- Full Question: Are we going back to pulse checks after defibrillation before resuming CPR?
- Consensus on Science: For the critical outcome of “survival with favorable neurological outcome at discharge” we identified very low quality evidence downgraded for serious risk of bias, indirectness and imprecision; from three observational studies enrolling 763 OHCA showing a harm effect for checking rhythm immediately after defibrillation (RR 0.62 95% CI 0.51-0.75) (Bobrow, 2008,1158; Kelliun,2006,335; Rea,2006,2760).
- Treatment Recommendation: The ILCOR recommends resuming compressions as soon as possible after shock and believes the science supports minimal interruptions of cardiac compressions. Based on this, we don’t believe pulse checks are coming back after defibrillation for 2015.
Starting CPR: CAB vs ABC (NO CHANGE)
- Full Question: Will the new guidelines go back to ABC vs. CAB for the initial treatment of sudden cardiac arrest?
- Consensus On Science: All studies found that CAB decreased the time to commencement of chest compression. The randomized trial found a statistically significant 24.13 second difference.
- Treatment Recommendation: Due to the overwhelming support of compressions first shortening the time before the initial compression being delivered, we believe that the compression, airway and breathing (CAB) form of treatment will remain the same for 2015.
Timing of CPR cycles (2 min vs other) (NO CHANGE)
- Full Question: The question was asked, “should the pause to check pulses be at any other interval than the 2 minutes of CPR mark?”
- Consensus on Science: Initial rhythm check only for the critical outcomes of “survival with good neurological outcome” and “survival” we have identified low quality evidence from one randomized controlled trial (RCT) 1 enrolling 9,993 patients, demonstrating no benefit in patients with out of hospital cardiac arrest (OHCA) with any initial rhythm.
- Treatment Recommendation: Due to the research, most probably no change will be made for the 2015 guidelines and the guideline will remain the same as 2010.