Guidelines on Use of CPR from the American Heart Association

Guidelines for the use of cardiopulmonary resuscitation (CPR) issued by the American Heart Association say that bystanders should refrain from checking the pulse of an unconscious victim before beginning CPR. This is in contrast to the old guidelines, in place since 1992. According to Tom P. Aufderheide, MD, Professor of Emergency Medicine at the Medical College of Wisconsin and a co-editor of the new guidelines, this was changed because the pulse check has been recognized as unreliable. The American Heart Association reports that bystanders are incorrect as often as 35% of the time when checking for a pulse.

"Bystanders, on average, take 24 seconds to determine if a pulse is present," Dr. Aufderheide said. "That time could be used to perform CPR or use an automated external defibrillator (AED) to restart the heart. Plus, in 10% of the cases, bystanders miss cardiac arrest when checking for a pulse. They think a heartbeat is present when the heart actually stopped beating. This represents missed opportunities to possibly save a life."

The guidelines now state that instead of performing CPR, members of the general public who know CPR should look for normal breathing, coughing, movement, response to stimulation and other signs of circulation when deciding whether to begin chest compressions or applying an AED.

The deletion of the pulse check from layperson CPR training has already been implemented in the United Kingdom and in Europe. The new guidelines do continue to recommend that trained healthcare professionals check for a pulse (in addition to looking for signs of circulation) before doing chest compressions on an unconscious victim.

Many individuals will be affected by the change in guidelines. Those who have previously been trained in CPR will need to be re-trained when their current certification expires. Tens of thousands of individuals in Wisconsin alone are trained in CPR each year by more than 4,100 certified CPR trainers The new CPR and advanced training materials will be available for widespread use by the summer of 2001.

"The new guidelines were developed using a rigorous evidenced-based process that maximized scientific accuracy, safety, cost effectiveness, and teachability," Dr. Aufderheide said. "Furthermore, the guidelines were developed by a liaison of the world's major resuscitation councils, making these the first internationally applicable guidelines.

The new guidelines emphasize the importance of automated defibrillators (AEDs) to increase sudden cardiac arrest survival. AEDs are easy to use. Two electrodes are applied to the chest and the device automatically senses the heart rhythm and determines whether a lifesaving electric shock is necessary. The AED prompts the user to deliver a shock and all the bystander has to do is press the "shock" button. Prompt bystander CPR combined with early defibrillation can significantly increase survival rates. The guidelines also stress the need for greater availability of AEDs -- and people trained to use them -- in fire trucks, ambulances, police cars, public buildings, sports arenas, theaters and airports.

Other new recommendations include:

• Streamlining and standardizing the ratio of chest compressions to breaths during adult CPR.
• Updated recommendations for emergency medical personnel such as medication treatment protocols for heart attacks, stroke and cardiac arrest in victims of all ages.
• Simplification of CPR instruction. For example, techniques to teach management of choking (airway obstruction) in an unconscious victim have been greatly simplified, based on evidence that chest compression in CPR creates enough pressure to eject a foreign body from an airway . The use of abdominal thrusts (the Heimlich maneuver) to clear an object from the airway of a conscious person will still be taught under the new guidelines.

The guidelines were published in the August 22 issue of Circulation.

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.