Summary of main changes since the 2010 to the Resuscitation Guidelines

Main changes in the 2015 Guidelines are summarised at the beginning of each guideline topic and are listed below.

Basic life support and automated external defibrillation

• Guidelines 2015 highlights the critical importance of the interactions between the emergency medical dispatcher, the bystander who provides CPR and the timely deployment of an automated external defibrillator (AED).
• The emergency medical dispatcher plays an important role in the early diagnosis of cardiac arrest, the provision of dispatcher-assisted CPR (also known as telephone CPR), and the location and dispatch of an AED.
• The knowledge, skills and confidence of bystanders will vary according to the circumstances, of the arrest, level of training and prior experience. The bystander who is trained and able should assess the collapsed victim rapidly to determine if the victim is unresponsive and not breathing normally and then immediately alert the emergency services. Whenever possible, alert the emergency services without leaving the victim.
• The victim who is unresponsive and not breathing normally is in cardiac arrest and requires CPR. Immediately following cardiac arrest blood flow to the brain is reduced to virtually zero, which may cause seizure-like episodes that may be confused with epilepsy. Bystanders and emergency medical dispatchers should be suspicious of cardiac arrest in any patient presenting with seizures and carefully assess whether the victim is breathing normally.

Advanced life support

• There is increased emphasis on minimally interrupted high quality chest compressions throughout any ALS intervention.
• Chest compressions must only be paused briefly to enable specific interventions. This includes minimising interruptions in chest compressions to less than 5 seconds when attempting defibrillation or tracheal intubation.
• There is a new section on monitoring during ALS.
• Waveform capnography must be used to confirm and continually monitor tracheal tube placement, and may be used to monitor the quality of CPR and to provide an early indication of return of spontaneous circulation (ROSC).
• There are a variety of approaches to airway management during CPR and a stepwise approach based on patient factors and the skills of the rescuer is recommended.
• The recommendations for drug therapy during CPR have not changed, but there is equipoise for the role of drugs in improving outcomes from cardiac arrest.
• The routine use of mechanical chest compression devices is not recommended, but they may be useful in situations where sustained high quality manual chest compressions are impractical or compromise provider safety.
• Peri-arrest ultrasound may be used to identify reversible causes of cardiac arrest.
• Extracorporeal life support techniques may be used as a rescue therapy in selected patients where standard ALS measures are not successful.
• The ALS algorithm has been modified slightly to show these changes.

Post-resuscitation care

• There is a greater emphasis on the need for urgent coronary catheterisation and percutaneous coronary intervention (PCI) following out-of-hospital cardiac arrest of likely cardiac cause.
• Targeted temperature management remains important but the target temperature can be either 36°C or 33°C according to local policy. There was a preference for 36°C among the guidelines group because it is easier to implement and there is no evidence that it is inferior to 33°C.
• Prognostication is now undertaken using a multimodal strategy and there is emphasis on allowing sufficient time for neurological recovery and to enable sedatives to be cleared.

Paediatric life support

• The duration of delivering a breath is about 1 second, to coincide with adult practice.
• For chest compressions, depress the lower sternum by at least one-third the anterior-posterior diameter of the chest, or by 4 cm for the infant and 5 cm for the child.
• In the presence of a febrile illness, if there are no signs of septic shock, children should be given fluid cautiously and then reassessed. In some forms of septic shock, restricted fluid resuscitation with isotonic crystalloid may be more beneficial than the liberal use of fluids.
• For cardioversion of a supraventricular tachycardia (SVT), the initial dose has been revised to 1 J kg^-1.
• Prevent fever in children who have return of spontaneous circulation (ROSC) after out-of-hospital cardiac arrest.
• In children, targeted temperature management can be with normothermia or mild hypothermia.

Resuscitation and support of transition of babies at birth

• For uncompromised term and preterm infants, a delay in cord clamping of at least one minute from the complete delivery of the infant, is now recommended. As yet there is insufficient evidence to recommend an appropriate time for clamping the cord in infants who are severely compromised at birth. For infants requiring resuscitation, resuscitative intervention remains the immediate priority.
• The temperature of newly born infants should be actively maintained between 36.5°C and 37.5°C after birth unless a decision has been taken to start therapeutic hypothermia.
• Preterm infants of less than 32 weeks gestation may benefit from a combination of interventions to maintain their body temperature between 36.5°C and 37.5°C after delivery, through stabilisation and neonatal unit admission.
• An ECG, if available, can give a rapid accurate and continuous heart rate reading during newborn resuscitation. It does not, however, indicate the presence of a cardiac output and should not be the sole means of monitoring the infant.
• Resuscitation of term infants should commence in air. For preterm infants, a low concentration of oxygen (21–30%) should be used initially for resuscitation at birth. If, despite effective ventilation, oxygenation (ideally guided by oximetry) remains unacceptable, use of a higher concentration of oxygen should be considered.
• Attempts to aspirate meconium from the nose and mouth of the unborn infant, while the head is still on the perineum, are not recommended.
• Nasal continuous positive airways pressure (CPAP) rather than routine intubation may be used to provide initial respiratory support of all spontaneously breathing preterm infants with respiratory distress.
• The recommended compression: ventilation ratio for CPR remains at 3:1 for newborn resuscitation. Asynchronous compressions are not recommended.

Prehospital resuscitation

• The team approach is emphasised.
• Supraglottic airways often provide an ideal airway and should be used as part of a stepwise airway management pathway. Tracheal intubation is attempted only by those with adequate training and only if simpler airways prove inadequate.
• There is no evidence that a pre-defined period of CPR before defibrillation improves success rates. Mechanical chest compression devices are a reasonable alternative to high quality manual chest compressions in situations where sustained high quality manual chest compressions are impractical or compromise provider safety.
• The use of waveform capnography is emphasised not only to indicate placement of a tracheal tube in the airway (and not the oesophagus), but also as a useful indicator of cardiac output and the effectiveness of chest compressions. A sudden increase in end-tidal CO₂ may be an early indicator of ROSC.
• After ROSC is achieved passive cooling is recommended in the prehospital phase.
• In patients with evidence of ST elevation, transfer to a cardiac arrest centre capable of performing PCI is the optimal care pathway.

Prevention of cardiac arrest and decisions about CPR

• Prevention of in-hospital cardiac arrest requires staff education, monitoring of patients, recognition of patient deterioration, a system to call for help and an effective response.
• Ensure that all clinical staff are trained in the recognition, monitoring, and management of critically ill patients, and that they know their role in the rapid response system.
• Ensure that all policies on CPR decisions are based on current national guidance, and ensure that all clinical personnel understand it.
• Identify those fully informed patients who do not wish to receive CPR, those patients for whom cardiorespiratory arrest is an anticipated terminal event and for whom CPR would be inappropriate, and those patients who have lost capacity in whom a decision not to attempt CPR is in their best interests.

In-hospital resuscitation

• There is continuing emphasis on the use of rapid response systems for care of the deteriorating patient and prevention of in-hospital cardiac arrest.
• There is continued emphasis on minimally interrupted high quality chest compressions throughout CPR: chest compressions are paused briefly only to enable specific interventions. This includes minimising interruptions in chest compressions to attempt defibrillation.

Peri-arrest arrhythmia

• The basic principles of assessment and treatment of a suspected cardiac arrhythmia are unchanged.
• Use of oxygen therapy is not recommended unless the patient is hypoxic, in which situation the concentration of oxygen delivered should be guided by monitoring arterial oxygen saturation whenever possible.
• There is stronger emphasis on the use of antithrombotic therapy in atrial fibrillation (AF) and the importance of assessing thromboembolic risk in people with AF.

Education and implementation

• All school children should be taught how to perform CPR and should be made aware of how to use an AED.
• Ambulance services should have access to a national database of AEDs and their dispatchers should have specific training in how to provide clear and effective instructions to rescuers over the telephone.
• Frequent ‘low-dose’ training may be a beneficial method for providing CPR/AED retraining.
• The outcomes for candidates attending an e-ALS course are the same as those attending a conventional 2-day ALS course.
• High-fidelity manikins are not essential for life support courses.
• Life support courses should incorporate training in non-technical skills (e.g. leadership, team behaviour and communication) into their curricula.
• Healthcare systems should evaluate their processes to ensure those with a cardiac arrest have the best outcomes.
• Teams who manage patients in cardiac arrest should use data-driven performance-focused debriefing.
• Social media and innovative technology have vital roles to play in improving outcomes from cardiac arrest.