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i n E m e r g e n c y C a r d i o v a s c u l a r C a r ei n E m e r g e n c y C a r d i o v a s c u l a r C a r e

Volume 11 Number 3Fall 2000

Volume 11 Number 3Fall 2000

Guidelines 2000for CardiopulmonaryResuscitationand EmergencyCardiovascular CareInternational Consensus on Science

Special Edition

Guidelines 2000for CardiopulmonaryResuscitationand EmergencyCardiovascular CareInternational Consensus on Science

Special Edition

CurrentsCurrents

2 Fall 2000 ©2000 American Heart AssociationCurrentsCurrents

CurrentsAn Official Publication of

the American Heart Association

and the Citizen CPR Foundation

Editor: Kathleen Jun

Currentsin Emergency Cardiovascular Care

Richard O. Cummins, MD, MPH, MScECC Senior Science EditorUniversity of Washington

Medical CenterSeattle, Washington

Mary Fran Hazinski, RN, MSNECC Senior Science EditorVanderbilt University Medical CenterNashville, Tennessee

Tom P. Aufderheide, MDECC BLS Science EditorMedical College of WisconsinMilwaukee, Wisconsin

Robert A. Berg, MDChair, AHA Pediatric

Resuscitation SubcommitteeUniversity of ArizonaTucson, Arizona

Ahamed H. Idris, MDChair, BLS SubcommitteeUniversity of FloridaGainesville, Florida

Richard E. Kerber, MDChair, AHA ECC CommitteeCardiology Division, University of

Iowa HospitalIowa City, Iowa

William H. Montgomery, MDPresident, Citizen CPR FoundationStraub Clinic and HospitalHonolulu, Hawaii

Vinay Nadkarni, MDECC Pediatric Resuscitation

Science EditorduPont Hospital for ChildrenWilmington, Delaware

Edward R. Stapleton, EMT-PECC BLS Science EditorState University of New YorkStony Brook, New York

F. G. Stoddard, PhDSenior Editor, ECC ProgramsAHA Office of Science and MedicineDallas, Texas

E D I T O R I A L A D V I S O RY B O A R DAHA ECC Website:cpr-ecc.americanheart.org

Currents in EmergencyCardiovascular Care is a quarterlypublication sponsored by theAmerican Heart Association andthe Citizen CPR Foundation andsupported by the American RedCross and the Heart and StrokeFoundation of Canada. Currentswas established to exchangeinformation about important ideas,developments, and trends inemergency cardiovascular care.Send editorial inquiries and lettersto Kathleen Jun at the AHA, ECCPrograms, 7272 Greenville Ave.,Dallas, TX 75231-4596. Phone1-800-242-1793, ext 9862; [email protected]. For bulkreprints, contact Julie Mallory at214-706-1658.

Subscriber ServicesCurrents in EmergencyCardiovascular Care is availableby free subscription in the UnitedStates and Canada with the helpof 11 underwriters, noted on theback cover of every issue. Individualsoutside these countries may registerto receive quarterly email noticesthat will link directly to each newissue of Currents when posted onthe ECC website. To register forthese subscriber services, call877-821-2010 toll-free from withinthe United States. Or sign up viathe internet at the AHA ECC websitewww.cpr-ecc.americanheart.org.You can also fax your registrationto 281-419-8238, ext 110. If youregister by fax, be sure to includeyour name, the courses you teach(PALS, BLS, etc), work and homeaddresses (specifying which touse for your subscription), phoneand fax numbers, and emailaddress as applicable. An entireroster of names may be sent atonce, but be certain to include allnecessary information. Missingissues? Call Mary Alcedo,214-706-1159; fax 214-987-9361;email [email protected] in the USA.

GST registration number: R 130 875 941.

©2000 American Heart Association

Matt Anderson, EMT-PNational Association of EMS

Training CoordinatorsJuneau, Alaska

Lance Becker, MDUniversity of ChicagoChicago, Illinois

John E. Billi, MDAHA ACLS SubcommitteeAnn Arbor, Michigan

Leo L. Bossaert, MDHon Secretary, European

Resuscitation CouncilAntwerp, Belgium

Kenneth P. Buchholz, MD, CCFPAnnapolis Royal, Nova Scotia

James M. Christenson, MD, FRCPCSt. Paul’s HospitalVancouver, British Columbia, Canada

Wes Clark, MScHeart and Stroke Foundation of CanadaOttawa, Ontario, Canada

Leonard A. Cobb, MDHarborview Medical CenterSeattle, Washington

Wolfgang F. Dick, MDJohannes Gutenberg University HospitalMainz, Germany

Edgar R. Gonzalez, PharmDMedical College of VirginiaRichmond, Virginia

Anthony Handley, MDChair, BLS Working GroupEuropean Resuscitation CouncilColchester, England

Svein A. Hapnes, MDNorwegian Resuscitation CouncilStavanger, Norway

Gordon HarrisonChairman, Australian

Resuscitation CouncilSydney, NSW, Australia

Stig Holmberg, MDChairman, Scandinavian

Resuscitation CouncilGöthenburg, Sweden

Allan S. Jaffe, MDMayo ClinicRochester, Minnesota

Rashmi Kothari, MDAHA ACLS SubcommitteeBorgess Research InstituteKalamazoo, Michigan

Dennis M. MurphyInternational Association of

Fire ChiefsSpringfield, Oregon

Richard M. Nowak, MDAmerican College of

Emergency PhysiciansDetroit, Michigan

Paul M. Paris, MDNational Association of

EMS PhysiciansPittsburgh, Pennsylvania

Peter Safar, MDDirector, Resuscitation

Research CenterPittsburgh, Pennsylvania

James S. Seidel, MD, PhDUCLA Medical CenterTorrance, California

Thomas E. Terndrup, MDChair, Department of

Emergency MedicineUniversity of Alabama

at BirminghamBirmingham, Alabama

Sergio Timerman, MD Co-Chairman, ECC CommitteeInterAmerican Heart FoundationSão Paulo, Brazil

Roger D. White, MD Mayo Clinic and Mayo

Medical SchoolRochester, Minnesota

C O N T R I B U T I N G E D I T O R S

©2000 American Heart Association 3Fall 2000 CurrentsCurrents

Richard O. Cummins, MD, and Mary Fran Hazinski,RN, MSN, Senior Science Editors, AHAEmergency Cardiovascular Care Programs

Chairs of the ECC Committee andSubcommittees and Science Editors of theAHA ECC Science Product Development Panel:(alphabetical) Tom P. Aufderheide, MD, Science Editor, Basic

Life Support; Robert A. Berg, MD, Chair, Pediatric Resuscitation

Subcommittee; John Field, MD, Science Editor, Advanced

Cardiovascular Life Support; Ahamed H. Idris, MD, Chair, Basic

Life Support Subcommittee; Richard E. Kerber, MD, immediate

past chair, ECC Committee; Karl B. Kern, MD, Chair, Advanced

Cardiovascular Life Support Subcommittee; Vinay M. Nadkarni,

MD, Science Editor, Pediatric Resuscitation and Chair-elect,

ECC Committee; Edward R. Stapleton, EMT-P, Science Editor,

Basic Life Support; Mark Swanson, MD, Chair, Program

Administration Subcommittee; Arno Zaritsky, MD, Science

Editor, Pediatric Resuscitation

International Editorial Board

Richard O. Cummins, MD, MPH, MSc (AHA); Mary Fran

Hazinski, RN, MSN (AHA); Peter J.F. Baskett, MD (European

Resuscitation Council [ERC]); Douglas Chamberlain, MD

(ERC); Leo L. Bossaert, MD (ERC); Vic Callanan, MD

(Australian Resuscitation Council [ARC]); Pierre Carli, MD

(ERC); Marc Gay, MD (Heart and Stroke Foundation of

Canada [HSFC]); Anthony J. Handley, MD (ERC); Ian Jacobs,

MD (ARC); Richard E. Kerber, MD (AHA); Walter G.J.

Kloeck, MD, BCh (Resuscitation Council of Southern Africa);

Pip Mason, RN (New Zealand Resuscitation Council); William

H. Montgomery, MD (AHA); Peter T. Morley, MD (ARC);

Martin H. Osmond, MDCM (HSFC); Colin Robertson, MD

(ERC); Michael Shuster, MD (HSFC); Petter A. Steen, MD

(ERC); James Tibballs, MD (ARC); Sergio Timerman, MD

(Latin American Council on Resuscitation); David A. Zideman,

MD (ERC)

Contents

Page 4 Overview and big-picture changes: international,

science-based guidelines; ACLS for Experienced Providers;

level of evidence defines class of recommendation; evidence-

based first aid: primary and secondary ABCD surveys

Page 6 Education, training, and examination: learning

objectives; open door to innovation; annotated examinations;

reconstruction of examinations; improving instructor quality

Page 8 Ethical concerns in resuscitation: family

presence during resuscitation; DNAR status; certification of

death in the field, not in the ED; survivor support

Page 9 BLS and PBLS: early defibrillation; special

situations; bag-mask ventilation; smaller tidal volumes;

mouth-to-nose breathing for infants; LMA; no pulse check

for lay rescuers; FBAO in unresponsive victims; chest

compression location; chest compression rate;

compression-ventilation ratio; CPR without mouth-to-mouth

ventilations; 2-thumb compression; AEDs for children

Page 13 Airway and ventilation (BLS and ACLS):airway devices and steps toward continuous quality for

airway management; airway devices

Page 16 PALS: special resuscitation circumstances;

bag-mask ventilation versus tracheal intubation; secondary

confirmation; postresuscitation interventions; LMAs;

intraosseous route; vagal maneuvers; amiodarone; epinephrine;

AEDs for children

Page 20 Neonatal resuscitation: ventilation;

meconium-stained amniotic fluid; chest compression

indications; 2-thumb technique; endotracheal intubation;

LMA; secondary confirmation; crystalloid solutions; ethical

issues; hypothermia and resuscitation; hyperthermia

Page 22 ACLS: algorithm changes—ILCOR, ECC;VF/pulseless VT; PEA; asystole, bradycardias, tachycardias;acute coronary syndromes; stroke; post-resuscitation care;toxicology; airway adjuncts

Page 27: To order texts and materials

Guidelines 2000 for CardiopulmonaryResuscitation and Emergency Cardiovascular Care

International Consensus on ScienceThe Major New ECC and CPR Guidelines


Overview ofthe International

GuidelinesThis special issue of Currentspresents the conclusions of the

International Guidelines 2000 Conference on Cardiopulmonary

Resuscitation (CPR) and Emergency Cardiovascular Care

(ECC). Face-to-face expert discussion and writing began

in March 1999. The Evidence Evaluation Conference that

followed in September 1999 was attended by more than 250

people and the Guidelines 2000 Conference in February 2000

was attended by more than 500 people. Review, debate,

discussion, and consensus continued via email, conference

call, fax, and personal conversation. A restricted-access website

posted drafts of the guidelines for download, review, revision,

and then reposting for further discussion and comments.

A long-term goal has been achieved: to create valid, widely

accepted international resuscitation guidelines based on inter-

national science produced by international resuscitation

experts. The Guidelines 2000 Conference was more than an

update of previous AHA recommendations for CPR and ECC

and similar recommendations published by the European

Resuscitation Council. This was the world’s first internation-

al application of a rigorous, evidence-based template to

specifically produce international resuscitation guidelines. At

all stages of planning, coordination, and implementation,

conference planners sought and achieved active involvement

of individuals and councils outside the United States.

The Guidelines 2000 Conference must not be considered

a solely American or AHA conference. Participants from

outside the United States comprised 40% of people attending.

At least 1 US scientist and 1 non-US scientist evaluated

each topic with the goal of creating a geopolitically neutral

work. Guidelines dominated by the opinions of 1 country or

1 resuscitation council would be unacceptable.

The term “new guidelines” encompasses more than new rec-

ommendations for drugs, medical devices, and interventions

not previously in the guidelines. “New guidelines” also

includes reappraisal of old recommendations that have been

reaffirmed, assigned for re-review, or removed. As much as

possible, all additions, removals, and reappraisals of resusci-

tation guidelines are the result of intense, evidence-based

review by experts, researchers, and highly experienced inter-

national clinical personnel.

Big-Picture ChangesACLS for ExperiencedProviders CourseExpanding the Scope of ECC: Prearrestinterventions➞arrest prevented➞stabilization

New Emergency cardiovascular care cannot concentrate

only on patients who have lost their pulse and are in full car-

diac arrest. Every day rescuers and clinicians encounter

patients “on their way to a cardiac arrest.” Appropriate inter-

ventions at this point may stabilize a patient, prevent further

deterioration, or even prevent an arrest altogether.

(Circulation,page I-372).

These more complicated problems cannot be covered in the

ACLS Providers Course. Therefore, the AHA ECC Programs

created and piloted a new course, ACLS for Experienced

Providers. This new course provides a renewal opportunity

for active ACLS providers and a continuing-education

opportunity for former ACLS providers.

The ACLS-EP Course provides guidelines for many challenging

conditions including asthma, anaphylaxis, electrolyte distur-

bances, and toxicology-induced disturbances in rhythm and

blood pressure, even to the point of death. Instructors for this

course are now responsible for teaching the guidelines on the

management of former “special resuscitation situations,” including

submersion, lightning strike, electrical injury, arrest associated

with trauma and pregnancy, and hypothermia. These are problems

that challenge ACLS providers all over the world every day. And

yet, until this year, the resuscitation community had never

focused attention on these topics.

Old After the change to case-based teaching in 1994, the

ACLS Providers Course concentrated on 10 core cases. Course

directors quickly learned that there was little to no time avail-

able to cover a long list of resuscitation problems that are spe-

cialized and require unique and specific treatments.

Why? In brief, to increase the range of cardiovascular emer-

gencies that ACLS providers can recognize and treat effec-

tively. Emergency treatment of life-threatening hyperkalemia,

for example, requires provider knowledge of 6 different med-

ications, given in precise amounts and in a specific sequence.

It became incumbent to develop ways in which these specific

lifesaving recommendations could be communicated to all

ACLS providers. The only reasonable approach seemed to be

the development of a new course, but one that closely

adhered to the ACLS Provider Course model. The ECC

Programs network considers this new course so important for

ACLS providers that participation in the ACLS-EP Course

will constitute renewal for active ACLS providers.


Levels of EvidenceNew The Guidelines 2000 Conference was the world’s first

internationally developed, science-based, and evidence-based

conference on resuscitation. All new guidelines were rigor-

ously reviewed, adhering to the principles of evidence-based

medicine. The Class I, IIa, IIb, III, and Indeterminate desig-

nations in parentheses after many guidelines indicate the

strength of evidence that supports that guideline. In general,

these designations are defined as follows:

Class Iguidelines are supported by excellent, definitive evi-

dence of effectiveness in humans; must have at least 1

prospective, randomized, controlled, positive clinical trial.

Major reasons a guideline is Class I:human, prospective,

randomized controlled trial; critically acclaimed; demon-

strates a high magnitude of benefit. Despite great enthusiasm

for a number of new guidelines, few met the criteria for a

Class I recommendation.

Class IIa guidelines are supported by very good evidence of

effectiveness and safety in humans. Many experts think of Class

IIa guidelines as highly recommended interventions or actions.

Major reasons a guideline is Class IIa:Multiple studies,

using good methodologies, obtain generally positive results.

A good example from the International Guidelines 2000:the

addition of glycoprotein IIb/IIIa inhibitors to the acute coro-

nary syndrome recommendations for unstable angina and ST-

segment depression.

Class IIb guidelines are supported by fair to good evidence

of effectiveness and safety in humans; no evidence of harm.

Many experts think of Class IIb guidelines as optional but

acceptable options.

Major reasons a guideline is Class IIb:multiple studies, using

good methodologies, generally obtain positive results.

Class Indeterminateinterventions or actions are proposed

guidelines with insufficient evidence to support a final

recommendation for clinical use. Often these are ideas at a

preliminary research stage, promising but in need of more

research at a higher level.

Class Indeterminatenow applies to several interventions and

actions that have been in the guidelines for many years. Review

of the supportive evidence, however, reveals that the original

adoption was probably not justified because of insufficient evi-

dence. Examples:the routine use of vasopressin for asystole or

lidocaine for shock-resistant VF.

Class III interventions or actions are almost always existing

guidelines that continue to be reviewed and researched. New evi-

dence or review of old evidence strongly suggests or confirms

the probability of harm. Class III interventions are not useful,

may be harmful, and thus are unacceptable.

Major reason a guideline becomes Class III:accumulating evi-

dence of harmful side effects or interactions.

Evidence-Based First AidPaving the Way for First Aid, CPR,and Defibrillation in the Workplace

New The International Guidelines 2000 introduce several

examples of evidence-based first aid guidelines developed by

expert consensus. CPR and AED training in the workplace

providesrecognition and therapy for the majority of workplace

cardiovascular emergencies. By adding evidence-based first aid

training, CPR instructors can now provide a complete package to

meet most regulatory requirements for training in the workplace.

(Circulation,page I-372)

Primary and SecondaryABCD Surveys A Unifying Approach to ACLSAssessment and Management

Reviewed and Reaffirmed Introduced in 1994,

ACLS training has reformulated cardiac arrest treatment

away from a rhythm-based treatment approach to a case-

based assessment/management approach. Each of the 8 steps

in these surveys calls for problem assessmentand then, on

the basis of this assessment, problem management.For easy

memorization, the surveys use an alphabetical sequence: the

Primary and Secondary ABCD Surveys.This approach pro-

vides direction for all ACLS providers and instructors and

dominates the display of the ACLS cardiac arrest algorithms

in 2000. (Circulation,page I-373)

Primary: Airway (open), Breathing (2 breaths), Circulation

(chest compressions), Defibrillation (use AED).

Secondary: Airway (advanced use of tracheal tubes),

Breathing (placement confirmation, check effectiveness),

Circulation (gain access to circulation; give drugs as indicated),

Differential diagnosis.


Education, Training,and Examination

Commitment to Educationand Training Based on CoreLearning ObjectivesOld The core learning objectives of the ECC courses have not

previously been identified and defined.

New The ECC Programs defined the core learning

objectives for each of the resuscitation specialties. The ECC

Subcommittees were asked: “What skills and knowledge should

all participants be able to demonstrate at the end of a successful

course?” (Circulation, pages I-7 to I-9)

Why? Clearly stated learning objectives are necessary to guide

curricula development, teaching techniques, and instructor and

learner evaluation.

Adding specific skills adds specific objectives

AHA courses may add specific skills, depending on course

purpose, the setting, and learners’ scope of practice. For

example, learners must meet specific skill objectives when

any of the following skills are added: child-infant CPR, use

of barrier or mask devices, techniques to correct foreign-

body airway obstruction, or integration of AED use into BLS

for victims older than 8 years.

Pediatric AdvancedLife Support

Core Training Objectives

Immediately after completing PALS trainingand for up to 2 years after, the successfulPALS provider should be able to

1. Reduce the risk of the most commoncauses of injury and death.

2. Recognize and initiate treatment forimpending respiratory failure, shock,and cardiopulmonary arrest.

a. Provide PBLS (open airway,rescue breathing, chestcompressions).

b. Provide advanced support ofoxygenation and ventilation.

c. Obtain vascular access.

d. Initiate appropriate resuscitativefluid and drug therapy.

3. Initiate the first 10 minutes ofresuscitation of the pediatric victimof cardiopulmonary arrest.

4. Provide support for familiesand providers in coping with achild's death

Adult and PediatricBasic Life Support


Immediately after initial basic CPR trainingand for up to 2 years after, a rescuer shouldbe able to

1. Reduce the risk of the most commoncauses of injury and death.

2. Recognize unresponsiveness (or otheremergency situations where resuscitationis appropriate).

3. Phone 911 in a timely fashion (or otheremergency phone number, eg, in-hospital).

4. Provide an open airway (usinghead tilt–chin lift or jaw-thrust techniques).

5. Provide ventilations (breathing) that makethe chest rise, using mouth-to-mouth ormouth-to–barrier device ventilations(bag-mask ventilation by healthcareproviders).

6. Provide chest compressions (usingcompression force that moves sternumdown the appropriate depth for victim’sage [lay rescuer] or that generates apalpable pulse [healthcare provider]).

7. Perform all these skills in a manner thatis safe for the rescuer, the patient, andbystanders.

8. (If healthcare provider) Show proficiencyin bag-mask ventilation for victims ofall ages and use of AEDs for victims8 years of age or older.


Open Door for Education andTraining Innovations (Circulation, page I-8)

New Many new adjuncts to education and training have

been developed and accepted for ECC training. Acceptance

can occur if the new approach is evidence-based, validated,

and shown to be effective at increasing skill acquisition and

longer-term skill retention. Some recent examples of

approved techniques follow:

Instructor-directed, videotape-mediated training.Currently accepted: “practice-as-you-watch” videotapes

(Braslow-Kaye-Todd), “watch-then-practice” videotapes

(Stapleton, Aufderheide). Currently not accepted or not vali-

dated: “passive-watching-motivational-informational” videos.

Auditory and/or visual prompts (includes the valuablevoice prompts supplied with most AEDs).These prompts

guide the learner in multiple aspects of performance (ie, com-

pression location, depth, and rate; ventilation rate and volume).

Currently accepted are those prompts that require hands-on prac-

tice such as audible counting devices, sequence directive devices,

and compression-force prompts.

High-tech ACLS and BLS simulatorsguide and improve the

learner’s performance by providing constant device-operator

feedback as the learner attempts the procedure. Currently accept-

ed: Laerdal ALS units, a validated computer-aided learning pro-

gram to maintain healthcare provider skills with AEDs.

Increasing the Value of Examination Part I: Fully Annotated Written ExamsSupporting Pre-test and Post-test Learning

New All ACLS, PALS, and BLS written exams now have

a companion annotated exam. The annotations state why

each of the possible answers in the multiple choice list was

either correct or incorrect and refer the learner to the appropriate

text references and page numbers. After learners complete an

answer sheet, course directors can use student grading,

instructor grading, or colleague grading followed by distribution

of annotated versions. Learners review the annotated version

for discussions of questions that were unclear, misunderstood, or

answered incorrectly. This increases a learner’s independence,

aids self-learning, and frees course time formerly required for

review of written exams. (Circulation, page I-9)

Old From 1992 to 1997 the written exams had only an answer

sheet, with no information on why the right answer was correct

or why the other answers were incorrect. Annotations to the

questions in the written exams were not offered.

Why? Learners and instructors need to know why a particular

answer is either right or wrong. Instructors have complained that

they sometimes did not understand why certain answers were

correct and others were wrong. Exams with annotated answers

have been found to be a valuable self-teaching technique.

Advanced CardiacLife Support


Upon leaving an ACLS course and for 2years after, the successful ACLS providershould be able to

1. Recognize and initiate treatment forprearrest conditions that may leadto a cardiac arrest, including acutecoronary syndromes, respiratoryfailure, and stroke.

2. Manage the first 10 minutes of anarrest due to ventricular fibrillation.

a. Provide BLS care, includingproper operation of an AED.

b. Provide proper operation of aconventional defibrillator.

c. Provide advanced airway supportof oxygenation and ventilationwith secondary confirmation oftracheal tube placement.

d. Obtain vascular access.

3. Correctly treat the 4 arrest rhythms.

a. VT

b. PVT

c. PEA

d. Asystole


Part II: Complete Reconstruction of the ECCWritten Exams (for ACLS, PEDS, and BLS)

New New questions for the written exams have been created,

pilot tested, and validated. The questions evaluate mastery of the

major learning objectives. Educational consultants participated in

the writing, evaluation, and validation of these exams.

Old The former written questions did not eliminate ambiguity

and confusion. The subject matter of the questions seldom

aligned with the learning objectives of the course.

Why? This was a long-requested program improvement initia-

tive, undertaken to increase the learning value of written exams

for both the learners and the instructors.

New Focus on Measuring andImproving Instructor QualityNew Emphasis on Consistency inthe Quality of Teaching

New Training centers will create levels of faculty within

the center to facilitate instructor training, mentoring, and moni-

toring. Instructor and instructor-trainer monitoring forms provide

detailed outlines for evaluating instructor and instructor-trainer

performance. Training centers will be able to develop their

instructor corps internally without having to rely on outside

regional faculty. AHA-prepared videos and other standardized

teaching tools allow for core material to be presented consistently

and concisely in every course.

Old Instructor training and monitoring required regional

faculty assistance, which was not always available within

the training center. Instructor monitoring was subjective,

with little or no written guidelines for instructor

performance evaluation.

Why? This initiative enables training centers to meet the

demands for instructor development using internal resources.

Training centers will have the autonomy they need to operate

effectively and efficiently in developing their instructors.

Ethical Concerns inResuscitation

Family Presence DuringResuscitation Attempts Valuedby Families and Loved OnesNew Pediatric critical care nurses pioneered studies

demonstrating that family presence during resuscitation attempts

produces positive psychological effects. This practice is

recommended by the International Guidelines 2000 provided it

is done with planning, staff acceptance, and a designated staff

member who offers this opportunity to the family and remains

with them during their presence at the resuscitation attempt.

(Circulation, page I-19)

Searching for and Honoring“Do Not Attempt Resuscitation”(DNAR) Status In Field, EmergencyDepartment, and HospitalReviewed and Reaffirmed Many individuals, exe-

cuting their right of self-determination, have declared they want

no one to attempt resuscitation if they show indications of dis-

tress (unresponsive, not breathing, no pulse). They wish this even

if they or their family have called the EMS system. This DNAR

decision often takes the form of living wills, advance directives,

or other documents and even bracelets and anklets worn on the

body. Valid expressions of self-determination must be honored;

to do otherwise is unethical and prohibited by law.

(Circulation, pages I-14 to I-16, I-18)

Certification of Death in the Field—No TransportDeath Pronouncement in the Field

Reviewed and Reaffirmed There are very few indi-

cations for transporting a victim of nontraumatic cardiac arrest

who has failed a successfully executed prehospital ACLS resus-

citation effort to an Emergency Department to continue the resus-

citation attempt. The danger to personnel and bystanders is

greater than the probability of resuscitating the victim.


Criteria for Pronouncement of DeathReviewed and Reaffirmed EMS systems should

develop criteria for stopping resuscitation attempts in the out-of-

hospital setting. Advanced life support personnel, in collaboration

with the on-line medical control physician, can gather clinical


information which will allow the medical control physician to

declare the patient dead.

This would comply with state law in most states where a proper-

ly licensed physician must certify death.


New With rare exceptions, resuscitation efforts in the field

should cease if the following criteria have been met:

Quality of the resuscitation attempt was satisfactorywith an adequate trial of BLS and ALS as demonstratedby the following:

• Achieved airway control with tracheal intubation or

advanced airway device, confirmed proper tube

placement, and secured tube to prevent dislodgment

• Achieved effective oxygenation and ventilation

• Shocked VF when present

• Gained access to circulatory system and administered

epinephrine (or vasopressin), atropine, and antiarrhythmics

as appropriate

• Considered, searched for, and corrected reversible causes

or special resuscitation circumstances

• Observed continuous and documented pulseless arrest after

all of the above have been accomplished

Reviewed for significant special resuscitationcircumstances:

• Profound hypothermia

• Toxin or drug overdose

Survivor support plans have been established in advanceand they are in compliance with state and local policies

(See new guideline at right: Survivor Support Plans)

• Are medical directors available for real-time consultations

and to authorize cessation of efforts? (Leaving the body at

the scene and supporting the survivors: Class IIa)

For patients meeting above criteria, urgent field-to-hospital

transport with continuing CPR is almost invariably futile.

Because harm to personnel is more likely than help to the

victim, such transports are now classed as Class III (harmful;

no benefit).

Survivor Support Plans

New EMS systems should allow healthcare providers to fol-

low the new international guidelines for stopping

resuscitative efforts in the field. This requires survivor

support plans. EMS systems must develop action steps

to support pronouncement of death in the field:

• EMS personnel must know and understand advance plans

on leaving the body at the scene, how to perform death

certification, and how to transfer to funeral establishments.

• On-scene family advocates (usually designated field

personnel) can help families accept nontransport of the

dead person, reporting the death properly, calling the

funeral home, calling a chaplain or family minister,

completing the death certificate, and providing support

and answering questions. (Circulation, page I-19)

Religious or nondenominational grief counseling helps signifi-

cantly. Determine when and where this counseling is available

and how counselors can be contacted.

Basic Life Support—Adult and Pediatric

This section identifies distinctions in the new BLS

guidelines between those for lay rescuers and those

targeting healthcare providers.

Importance of Early DefibrillationConventional and Automated External

Reviewed and Reaffirmed Since the 1992

Guidelines, early defibrillation has been the preeminent

therapeutic intervention that saves lives of adult victims.

Evidence accumulated in the past decade continues to reaffirm

all guidelines having to do with early defibrillation, including

recommendations for timely defibrillation in public places,

in the homes of high-risk patients, and in commercial aircraft,

airports, hospitals, doctors’ offices, and outpatient clinics.

New Expand authorization for adult victims. The International

Guidelines 2000 highly recommend that authorization to attach

and operate a defibrillator be expanded to nontraditional respon-

ders such as police, firefighters, and security personnel in casi-

nos, on the ground, and in airports. In fact, as reviewed in other

sections, the perceived value of antiarrhythmics, vasopressors,

advanced airway control, oxygenation, and ventilation has


declined markedly since 1992. The evidence is disappointingly

weak that any of these interventions convey effective benefit to

cardiac arrest victims when applied universally.

New Remove barriers. Constructive efforts to remove state

and local administrative and regulatory barriers to the use of

AEDs by lay responders are strongly encouraged. In the majority

of states this has required introduction and sponsorship of revi-

sions to state legislative code.

New Insight The relative value of early defibrillation in

reducing the interval between adult sudden cardiac arrest and

first defibrillatory shock by 1 to 2 minutes does more to improve

the probability of survival for an individual patient than all the

medications, airway interventions, and newly designed defibrilla-

tion waveforms combined.

Recognition of Special SituationsThat Modify the “Phone First versusPhone Fast” Guidelines(Circulation, page I-256)

New Providers of adult and pediatric BLS recognize

clinical exceptions to the “phone fast” guideline (applies to chil-

dren up to 8 years) and the “phone first” guideline (applies to

children 8 years and older). The major exception to the “phone

fast” rule is those children (<8 years old) known to be at risk for

VF/VT who experience sudden witnessed collapse. Follow the

“phone first” guideline in such situations. This results in more

rapid arrival of a defibrillator. This situation was noted as a

“special resuscitation situation.”

New (for adults) In parallel to this new PALS guideline, adult

BLS guidelines also recognize 4 special resuscitation situations

where airway compromise, rather than sudden VF/ VT, is the

cause of the arrest. The new BLS guideline for these victims is

“phone fast,” that is, provide 1 minute of CPR before phoning

the EMS system. These situations are

1. Submersion/near-drowning (1 minute CPR; then“phone fast”)

2. Poisoning, drug overdose (1 minute CPR; then“phone fast”)

3. Trauma (1 minute CPR; then “phone fast”)

4. Respiratory arrest (1 minute CPR; then “phone fast”)

Old “Phone fast” was the guideline to follow for infants and

children under 8 years of age. “Phone first” was the guideline to

follow for victims 8 years of age through adult.

Why? To keep the sequence for lay rescuer CPR simple, con-

sistent messages should be given. To maximize survival from

cardiac arrest, however, rescuers should tailor rescue sequences

to best meet the needs of the collapsed victim. As a compromise

between educational simplicity and the needs of the individual

victim, the ECC scientists recommended that the simple message

be continued but that information in the texts address exceptions

to the rule. When appropriate, healthcare providers can suggest

that family members learn a different sequence, if appropriate.

Bag-Mask Ventilation Is aSkill That All BLS HealthcareProviders Must MasterNew Anyone providing prehospital BLS care for adults,

infants, and children should be trained to deliver effective oxy-

genation and ventilation using a bag-mask technique as the pri-

mary method of ventilatory support, particularly if the transport

time is short (Class IIa). (Circulation, pages I-267 to I-268)

Old The need for bag-mask ventilation was not emphasized,

and insertion of a tracheal tube was recommended as soon

as possible.

Why? Bag-mask ventilation provides effective ventilation

when performed by properly trained providers. In a Los Angeles

study, the EMS system had short transport times and the

providers were inexperienced, but trained, in pediatric intubation.

Study data showed that children who received bag-mask ventila-

tion had survival rates equivalent to those who received tracheal

intubation. Bottom line: bag-mask ventilation is a fundamental

skill that should be mastered by all healthcare providers.

Smaller Tidal Volumes DuringAdult Rescue BreathingNew Rescuers should now deliver smaller tidal volumes dur-

ing ventilation with bag-mask ventilation or when supplementary

oxygen is available. Rescue breaths delivered by mouth-to-

mouth or mouth-to–barrier device should average 700 to 1000

mL delivered over 2 seconds. If supplementary oxygen is


available, the skilled rescuer should attempt to provide smaller

tidal volumes during mouth-to-mask and bag-mask ventilation,

theoretically 400 to 600 mL over 1 to 2 seconds (Class IIb).


Old Provide tidal volume of 800 to 1200 mL during mouth-

to-mouth or mouth-to-mask or bag-mask ventilation.

Why? Smaller tidal volumes with oxygen supplementation

and/or bag-mask ventilation can support adequate oxygen satura-

tion but reduce the risk of gastric inflation (and its attendant

complications). If the smallest tidal volumes are used, the chest

should rise visibly and the oxygen saturation should be main-

tained. Note that smaller ventilation volumes can be associated

with hypercarbia and acidosis.

Mouth-to-Nose Breathing Is anAcceptable Alternative to Mouth-to-Nose-and-Mouth or Mouth-to-MouthRescue Breathing for an InfantNew Mouth-to-nose breathing is an acceptable alternative

to mouth-to-nose-and-mouth or mouth-to-mouth breathing if

the rescuer is unable to cover the infant’s nose and mouth

(Class IIb). (Circulation, pages I-265 to I-266)

Old Only mouth-to-nose-and-mouth and mouth-to-mouth res-

cue breathing were recommended. Mouth-to-nose breathing in

adults was offered as an alternative in the adult BLS 1992

Guidelines: “This technique is more effective in some patients

than the mouth-to-mouth technique. The mouth-to-nose tech-

nique is recommended when it is impossible to ventilate through

the victim’s mouth, the mouth cannot be opened (trismus), the

mouth is seriously injured, or a tight mouth-to-mouth seal is dif-

ficult to achieve. …” (JAMA, pages 2187-2188)

Why? Studies have shown that some rescuers may have

difficulty covering both the mouth and nose of an infant with

the rescuer’s mouth. In addition, these same studies have

shown that mouth-to-nose breathing may provide effective

ventilation of infants.

Consideration of AlternativeAirway Devices (LMA) forTrained Healthcare ProvidersNew Use of alternative advanced airways should be encour-

aged when rescuers are properly trained in their use (Class

Indeterminate). (Circulation, page I-297)

Old Tracheal intubation was thought to be the gold

standard for airway control.

Why? Several studies have documented the high complication

rate that can occur in some EMS systems when tracheal

intubation is performed by rescuers with limited experience in

performing pediatric intubation. Therefore, alternative techniques

to help isolate the airway and reduce gastric inflation are encour-

aged when rescuers are properly trained.

The “Pulse Check” Should Not BeTaught to Lay Rescuers New In the ABC sequence of CPR, lay rescuers will no longer

be taught to check for a carotid pulse. Instead they will be taught

to look and examine for “signs of circulation,” which include

normal breathing, coughing, or movement (Class IIa). If no signs

of circulation are detected, the rescuer should begin chest com-

pressions and attach an AED, if available. (Circulation, pages I-

39 to I-40 and I-269)

Old Lay rescuers were taught to palpate the carotid artery

located on the same side of the neck as the rescuer and, taking no

more than 10 seconds, decide whether they could feel a pulse. If

they felt no pulse, they would begin chest compressions and

attach the AED.

Why? Lay rescuers perform the pulse check primarily as the

signal to start chest compressions and, if trained as a Heartsaver

AED provider, to call for and attach an AED. Considerable evi-

dence demonstrates that rescuers have trouble locating the cor-

rect place for palpation. They require much more than the recom-

mended upper limit of 10 seconds. Finally, when palpating in the

correct location for as long as needed, the rescuer is unacceptably

inaccurate. A serious type II or false-negative error is committed

10% of the time. This leads to 1 of 10 cardiac arrest patients not

receiving either chest compressions or AED attachment.

Dropping the pulse check will not result in as much potential

harm as keeping the pulse check.

Simplification of Maneuvers for LayRescuer Relief of Foreign-BodyAirway Obstruction in theUnresponsive Victim of Any Age(Class IIb)New Previously recommended maneuvers for relief of

foreign-body airway obstruction (FBAO) in the unconscious

victim will no longer be taught to lay rescuers. Instead the lay

rescuer will begin standard CPR when an unrelieved responsive,

choking victim becomes unresponsive, or an unresponsive

person suspected of an FBAO is encountered, evaluated, and

treated. The only difference from regular CPR is that the rescuer


should open the airway widely whenever ventilations are

attempted to look for a foreign object and remove it if seen.

Blind finger sweeps should NOT be used by lay rescuers for

victims of any age. Healthcare providers will still perform the

sequence for relief of FBAO in unresponsive victims.

(Circulation, pages I-46 to I-48)

Old The sequence for relief of FBAO in the

unresponsive/unconscious victim required that the lay rescuer

attempt and reattempt ventilation, open the mouth with a tongue-

jaw lift, look for a foreign body, and remove it if seen, perform-

ing blind finger sweeps for adult victims. If no object is seen in

the mouth, the rescuer was instructed to perform 5 back blows

and 5 chest thrusts for infants and 5 abdominal thrusts for the

child (1 to 8 years) and the adult (>8 years of age). The rescuer

then starts the sequence again (attempt, reattempt ventilation, etc)

until the airway is clear and ventilations are successfully given.

After that the sequence of CPR resumes.

Why? In the United States, fewer than 3000 people a year

die from choking compared with more than 20,000 children a

year dying from trauma and more than 225,000 adults dying

from sudden cardiac arrest. Relief of FBAO in the responsive

infant, child, and adult is still thought to be extremely important

to prevent choking deaths, and those skills will continue to be

taught. Relief of FBAO in the unresponsive/unconscious victim,

however, is an extremely complex skill that requires considerable

time and practice to master. In the interest of simplifying the

CPR curriculum to make it more likely that the lay rescuer

will be able to respond to the more numerous victims of cardiac

or respiratory arrest, the complex sequence for lay-rescuer

relief of FBAO in unresponsive victims is deleted. In addition, a

recent study of adult cadavers found that chest compressions

generated at least as high or higher intrathoracic pressures

than abdominal thrusts, so chest compressions used in CPR

may enable dislodgment of an FBAO in an unresponsive victim.

Healthcare providers will still perform the complete sequence

for relief of FBAO in unconscious victims of all ages.

New Directions for Findingthe Location for AdultChest CompressionsNew CPR training for lay rescuers will use the phrase “in the

center of the chest, right between the nipples” to teach rescuers to

locate the point on the adult chest for chest compressions.


Old “Rescuer’s hand locates the lower margin of the victim’s

rib cage on the side next to the rescuer; the fingers are then

moved up the rib cage to the notch where the ribs meet the lower

sternum in the center of the lower part of the chest; the heel of

one hand is placed on the lower half of the sternum, and the other

hand is placed on top of the hand on the sternum so that the hands

are parallel; the long axis of the heel of the rescuer’s hand should

be placed on the long axis of the sternum.” (JAMA, page 2189)

Why? The old directions are unnecessarily complex and diffi-

cult to visualize. Principles of adult education mandate “the sim-

pler the better” and “the more steps teachers teach, the more steps

learners forget.” Requirements for such high precision intimidate

many lay learners and are unnecessarily precise. Both direc-

tions—“between the nipples” and “2 fingers above the xiphoid-

sternal notch”—arrive at close to the same anatomic location.

This is a new training guideline, not a new locationguideline.

Emergency medical dispatcher–assisted CPR instructions have

used “right between the nipples” for more than 15 years with no

reports of problems and with documented ease of communication.

New Chest Compression Rate forAdults (see also next new guideline)

New The new chest compression rate for adult victims,

whether used in 1- or 2-rescuer CPR and by lay rescuers AND

healthcare professionals, is approximately 100 compressions per

minute (Class IIb). (Circulation, page I-41)

Old The old chest compression rate was a range: 80 to 100

compressions per minute.

Why? Much evidence supports the following statements:

for chest compressions, the faster the better in terms of blood

flow and blood pressure. Frequent interruptions in compres-

sions significantly reduce overall blood flow, with longer

periods of no to very low flow. Rescuers, working within the

range of 80 to 100, will naturally drift toward the lower end

of the range, especially with the fatigue of providing several

minutes of chest compressions. Eliminating a rate range and

mandating a specific high rate will influence lay rescuers to

use the faster and more effective rate.

Adult Compression-Ventilation RatioNew For adult victims, 2 rescuers should no longer use a com-

pression-ventilation ratio of 5:1. They should use only a com-

pression-ventilation ratio of 15:2 (Class IIb) until the airway is

secured. (Circulation, page I-41)

Old Two rescuers should always use a compression-ventilation

ratio of 5:1.

Why? The ratio of 5:1 produces many interruptions of

chest compressions while the 2 ventilations are given. This


leads to marked reduction in blood flow and blood pressure.

With a 5:1 ratio the single ventilation, sandwiched between

short periods of rapid chest compressions, leads to faster,

more forceful ventilations from the rescuers. This in turn

leads to greater risks for gastric inflation, regurgitation, aspira-

tion, and severe lung damage.

Reaffirmed The 5:1 ratio should be used in pediatric arrest

by professional responders regardless of whether 1 or 2 rescuers

are involved.

Why? This topic has been reviewed several times since 1992.

There is no evidence to justify a change. Emphasis on oxygena-

tion and ventilation is justified in infants and children based on

the epidemiology of cardiac arrest.

“CPR” Performed Without Mouth-to-Mouth VentilationsReviewed and Reaffirmed CPR with compressions

and ventilations remains the ideal method of maintaining blood

flow until the arrival of a lay responder with an AED or EMS

personnel. However, if unwilling to perform mouth-to-mouth

rescue breathing for an adult victim, the rescuer should access

the EMS system, open the airway, and perform chest

compressions at the rate of approximately 100 compressions

per minute (Class IIa). (Circulation, page I-43)

CPR without ventilation may be taught by emergency

medical dispatchers (Class IIa).

The 2 Thumb–Encircling HandsChest Compression Technique IsRecommended Over the 2-FingerCompression Technique for 2-RescuerInfant CPR by Healthcare Providers

New The 2 thumb–encircling hands technique of chest com-

pression is preferred for chest compressions in infants performed

by healthcare providers when 2 rescuers are available (Class IIb).


Old The 2 thumb–encircling hands technique was an alterna-

tive technique for chest compression in the neonate.

Why? Data show that the 2 thumb–encircling hands tech-

nique can provide better blood flow than the 2-finger technique.

However, a single rescuer providing chest compressions using

this technique may have difficulty alternating between rescue

breathing and chest compressions. For simplicity and retention,

this technique is not taught to the lay rescuer and anyone per-

forming 1-rescuer CPR.

Use of Automated ExternalDefibrillators Is Encouraged forVictims of Cardiac Arrest OlderThan About 8 Years of Age orAbout 25 kg (55 lbs), AlthoughData Is Regarding the Use of AEDsin Pediatric Victims Are Limited

Reviewed An AED can be used in children 8 years of

age and older. The mean weight of an 8-year-old is 25 kg (55 lbs).

At that weight, an adult biphasic defibrillator will provide

nonescalating defibrillation energy doses of 150 J (6 J/kg) for

a 25-kg child. A monophasic defibrillator with escalating

dose will provide approximately 200 J (8 J/kg) for a 25-kg

child initially and then higher doses. Available evidence suggests

that these devices are accurate in differentiating between

shockable and nonshockable rhythms for adolescents. Note

that the guidelines still suggest the use of defibrillators with

adjustable energy dose for in-hospital use in areas that routinely

care for infants and children (Class IIb). (Circulation,page I-271)

Management ofthe Airway and

VentilationNew Airway AdjunctsNew The guideline sections on airway management and

ventilation contain the greatest number of new recommendations.

Most of these recommendations apply to healthcare providers

at both the BLS and ALS level. (Circulation,page I-95)

Why? New evidence. Since the 1992 Guidelines, many

scientists, researchers, corporate engineers, and entrepreneurs

have provided new information, new products, and new insights.

New evidence addresses ventilation volumes, ventilation

rates, maintenance of oxygenation, and prevention of hypercarbia,

acidosis, and aspiration. The international collaboration for

the International Guidelines 2000 increased awareness of

many devices and techniques that would otherwise have

remained unknown to the AHA training network.

The most important airway and ventilation developments come

from quality assessment efforts and outcome evaluation projects

conducted by a number of national and international centers.

These efforts have given us valuable information on the relative

merit of different devices and approaches. More important, this

work has stunned the resuscitation community by unequivocal


demonstrations of a sobering fact: healthcare providers in their

best-intentioned efforts to save lives have the capacity to severely

harm their patients.

The Guidelines 2000 Conference experts, leaders, and

participants examined this material carefully, adhering to the

principle of “first, do no harm” (Circulation,page I-380). These

reviews and discussions coalesced into a number of consensus

principles as powerful as any specific guideline. These new

airway guidelines require continuous quality improvement

initiatives that center on outcome assessment. The most

successful efforts are invariably found in programs where the

directors and managers adhere to the following approaches:

1. Examine carefully the ALS and BLS airway support

techniques used in various clinical settings.

2. Move these examinations beyond structural descriptions (how

many medics per population) and process descriptions

(average number of tracheal intubations per medic per year) to

focus on measuring health status outcome (survival to

hospital discharge of patients intubated versus not intubated in

the field).

3. Weigh these outcome evaluations against the training, skill

level, and experience of ALS providers in a given ALS system

or code responders in a given hospital. In addition, all patient

and system characteristics that can affect the evaluation

outcome must be considered (eg, witnessed versus

unwitnessed arrests, bystander CPR versus none, short

versus long transport times to hospitals, field use versus

prohibited use of paralytic agents, and high versus low

annual case frequency).

4. From these evaluations decide if the outcomes are satisfactory.

If not, question whether the sophistication and training

requirements for use of the airway devices match the skill

levels and experience of the emergency care providers.

5. Next, consider alternative action steps that might be

needed for an improvement process.

6. Select and develop action plans that address the problems

identified in this improvement process.

7. Observe the outcomes from the action plans.

8. Adjust training, programs, protocols, and equipment

as necessary.

9. Continue to monitor.

Airway Devices (Bag-Mask, TrachealTube, LMA, Combitube) for TrainedHealthcare Providers New (BLS, ACLS, PALS) Extensive evidence that

became available over the past decade provides these new guide-

lines on airway adjuncts:

New Bag-mask ventilation versus tracheal intubation.

Properly used by skilled BLS providers, the self-inflating, valved

bag with oxygen supplementation and continuous cricoid pres-

sure can be as effective as a tracheal tube in measures of oxy-

genation, ventilation, and protection from aspiration for short

ventilation times. (Circulation,page I-95)

New Dangers of tracheal intubation. Several curriculum

changes in established national training programs allow selected

BLS healthcare providers to be trained in the skills of tracheal

intubation. New evidence, however, reveals that unrecognized,

uncorrected esophageal intubations or tube dislodgments occur

with unacceptable frequency. One project prospectively studied

pediatric, out-of-hospital tracheal intubation attempts by

paramedics. The research leaders discovered that upon arrival at

the Emergency Department, 8% of these pediatric victims were

found to have a tube in the esophagus or hypopharynx. In another

out-of-hospital study of a large, mostly adult group of cardiac

arrest victims, more than 25% were found to have esophageal

or pharyngeal tube placement. (Circulation,page I-100)

New Secondary confirmation techniques. When tracheal intu-

bation is attempted, proper placement of the tube in the trachea

must be confirmed 2 ways: with primary confirmation techniques

and secondary confirmation techniques. Primary techniques

include physical examination: visualization of the tube passing

through the cords, 5-point auscultation, bilateral chest expansion,

tube condensation. In secondary confirmation techniques,

esophageal detector devices are preferred for intubation confir-

mation in adult cardiac arrest victims; end-tidal CO2 detectors are

preferred in non–cardiac arrest victims (Class IIa for victim with

spontaneous perfusion; IIb for victim in cardiac arrest).


New Prevention of tracheal tube dislodgment. After successful

tracheal intubation of adult victims, apply a manufactured tracheal

tube holder to prevent dislodgment, especially for patients who

must be moved and transported while intubated (Class IIa).

Homespun tape and string techniques should be abandoned since

they lack acceptable validation. Note that because the rate of unrec-

ognized tube dislodgments is low in most hospitals and EMS sys-

tems, the sample size required to achieve proper validation of tra-

cheal tube holders is prohibitively large. (Circulation,page I-101)


New Detection of tracheal tube dislodgment. After successful

tracheal intubation, use continuous end-tidal CO2 monitoring

(Class IIb) to provide early detection of tube dislodgment. Two

types of devices are acceptable: either the capnometer, which

provides a single numeric CO2 value, or the capnograph, which

provides a continuous visual display of the level of expired CO2.

Capnography is preferred because it provides continuous infor-

mation and is more sensitive but the cost is much higher.


New Four adult alternative advanced airway devices.

(Circulation,page I-98) The Guidelines 2000 Conference evalu-

ated the evidence supporting 4 new alternative airway devices:

the Class IIa esophageal-tracheal Combitube (ETC), the Class IIa

laryngeal mask airway (LMA), the Class Indeterminate pharyn-

gotracheal lumen airway (PTL), and the Class Indeterminate

cuffed oropharyngeal airway (COPA). The LMA and the ETC

alternative airways share the following characteristics:

• Both are advanced airway techniques, are placed orally, and are

inserted past the hypopharyngeal space but not into the trachea.

• Both are inserted blindly, without the need of a laryngoscope

to observe passage through the cords. This single feature is

the reason the LMA and the ETC have attracted so much

attention. Their ease of use, lack of requirements for training

in the difficult skill of laryngoscopy, and considerable

cost-savings are significant variables. These variables

mean that selected, out-of-hospital BLS care providers can

be trained in the use of these devices. This will bring many

of the considerable advantages of the gold standard—

tracheal intubation—to many more victims.

• Both offer protection from aspiration and the severe

consequences of aspirated stomach contents into the lungs.

• In some settings, these devices may be superior to the

bag-mask technique in both ventilation and oxygenation

in adults.

• Of some surprise, in many respects both devices have

proved to be equivalent to the definitive airway

management device, the tracheal tube, in adults.

Old (BLS) Healthcare providers at the BLS level were

taught that their airway device of first choice was a self-inflating

bag with a one-way valve, a side port for supplemental oxygen,

and a properly fitting face mask.

Old (ACLS/PALS) Healthcare providers at the

ACLS/PALS level were taught that the airway device of choice

was the tracheal tube, used with a valved self-inflating bag, with

ports to provide high-flow supplemental oxygen.

Old Policies Versus New GuidelinesBasic-level healthcare providers have been forbidden throughout

most of the United States, often by legislative regulation, from

“invading” the victim’s body during resuscitation efforts. The

S-shaped oropharyngeal airway is the most invasive airway

device ever permitted for BLS personnel, yet even that makes

many EMS medical directors uncomfortable.

With these two new airway devices, the International Guidelines

2000 create a difficult situation for the EMS constituency.

Extensive review of the evidence leads the AHA and the world’s

resuscitation councils to now recommend the use of two new

invasive airway devices. The evidence confirms that under

certain conditions each is clinically superior to the bag-mask

and clinically equivalent to the tracheal tube. Does this mean

paramedics must switch from using the tracheal tube to using

the LMA? Does this mean the basic healthcare provider must

be trained to use the LMA or the ETC and must switch from

the bag-mask to the other devices?

To answer these questions, many factors must be considered. The

AHA and the International Guidelines 2000 Conference cannot

engage in what are now more policy and regulatory factors than

clinical and evidence-based issues. Each EMS system should

review the continuous quality improvement principles, as well as

the evidence supporting the new alternative airway devices,

before making decisions on these new airway guidelines.


Pediatric Advanced Life Support

Early identification of critical illness (respiratory failure

and shock) and implementation of advanced life support to

prevent cardiac arrest continue to be emphasized in the new

guidelines. The default sequence of PALS interventions is

based on the most common cause of arrest for a given age

group. New information is provided to help the participant

to identify and treat special resuscitation circumstances that

may alter the ALS intervention approach.

Cardiac Arrest and CardiovascularEmergencies Related to SpecialResuscitation Circumstances: DrugOverdoses, Toxins, ElectrolyteAbnormalities, Asthma, andAnaphylaxis

New Slightly modified approaches to resuscitation and

advanced life support are provided for infants and children with

suspected drug toxicity or poisoning, such as cocaine

or ß-blocker overdose, or suspected electrolyte emergencies.


Old PALS rescuers should “seek and treat” reversible

causes, but no specific information regarding modification of

existing algorithms or treatment approaches was offered.

Why? We now know more about specific arrhythmias and

the cardiovascular effects of drug toxicities and poisonings.

In addition, the old PALS course was not designed to teach

advanced provider therapies and interventions. As more

providers have mastered the previous course content, it was

necessary for the course to evolve to meet the needs of these

trained providers. The advanced life support provider

can now apply PALS guidelines with specific recommendation

for managing common poisonings, toxicologic problems, and

electrolyte abnormalities.

Bag-Mask Ventilation VersusTracheal Intubation by PediatricHealthcare ProvidersReviewed and Reaffirmed All healthcare providers

who provide prehospital care for infants and children must be

trained to provide effective oxygenation and ventilation using

the bag-mask technique. This is an essential core skill for all

healthcare providers.

New For out-of-hospital PALS-level providers, ventilation via

a tracheal tube continues to be recommended under specific con-

ditions. A properly placed and secured tracheal tube is the most

effective and reliable method of assisted ventilation and has long

been considered the gold standard. However, this method

requires initial mastery and continued practice or frequent field

use to maintain safe and effective technical skills.


Tracheal intubation in unconscious patients should be

encouraged only for healthcare providers well trained

in performing this skill, verified by significant and

frequent field experience, and continually monitored

by an ongoing quality-improvement program.

Old In the out-of-hospital setting, for pediatric emergencies,

ventilation via a properly placed tracheal tube is the most

effective and safest ventilatory method. (While this statement

remains true and is still a part of the guidelines, proper

insertion and reliable maintenance of the tracheal tube are

difficult, particularly in EMS systems where paramedics

have infrequent opportunity to attempt intubation.)

Why? Recent research has confirmed new observations

about pediatric airway maintenance and ventilation in the

out-of-hospital setting: (1) properly performed bag-mask

ventilation is safer and more effective than previously realized,

particularly when transport time is short and (2) tracheal tube

intubation is more difficult to master and more dangerous

than previously realized. These observations together suggest

a restatement: bag-mask ventilation may be equivalent to

tracheal tube intubation for respiratory emergencies in some

out-of-hospital pediatric ALS settings.

Bag-mask ventilation, compared with tracheal tube intubation,

can provide equally effective ventilation and oxygenation in

prehospital settings where transport times are short. One urban

EMS system with short transport times and trained providers

with infrequent pediatric intubations in the field observed that

children who required ventilatory support had equivalent sur-

vival rates regardless of whether they received bag-mask venti-

lation or ventilation through a tracheal tube placed in the out-

of-hospital setting. Other studies confirm that in some EMS

systems the success rate for pediatric intubation is mediocre,

with unacceptably high rates of complications.


Recommendations for SecondaryConfirmation of ProperTracheal Tube Placement(Circulation, pages I-301 to I-303)

New Any EMS system that authorizes tracheal intubation

must ensure proper initial training, monitoring of skill retention,

and ongoing monitoring of safety and effectiveness. In

addition, providers must always assess tracheal tube placement

by primary confirmation using physical examination techniques

plus one or more secondary confirmation techniques (Class

IIa). The techniques for secondary confirmation include

qualitative end-tidal CO2 detectors and quantitative and

continuous CO2 measurement (capnometry versus capnography)

as well as devices that specifically detect tubes located in

the esophagus.

Specific approaches to prevent tube dislodgment should be

identified, such as use of commercially manufactured tube

holders. This is especially true for the prehospital setting in

which patient and transportation movements greatly increase

the risk of dislodgment.

Old Previous guidelines recommended clinical (and later radi-

ographic) confirmation of proper tracheal tube placement, with

visual inspection of the tube and vocal cords if any doubt arose

about tube placement. The old guidelines also noted that an end-

tidal CO2 detector can enable verification of tracheal tube place-

ment and early recognition of tube dislodgment in infants larger

than 2 kg during stabilization and transport.

Why? Unrecognized incorrect tube placement or subsequent

unrecognized tube dislodgment is typically a fatal complication.

If tracheal intubation is attempted, the healthcare provider is

obligated to ensure that the tracheal tube is placed correctly. A

randomized, controlled trial of bag-mask ventilation versus tra-

cheal intubation observed a remarkably high complication rate

with tracheal intubation performed by inexperienced providers.

In this study, 1 of every 11 tracheal tubes placed in children was

in the esophagus or above the vocal cords.

Exhaled CO2 is a particularly reliable indicator of tube placement

if the child has a perfusing rhythm. In cardiac arrest, the

sensitivityand specificity of these devices are lower than when

a perfusing rhythm is present. Both the 1992 and the 2000

Guidelines note that a low end-tidal or exhaled CO2 detector can

mislead the provider into mistakenly suspecting esophageal

intubation in children with cardiac arrest, even though the

tube is in the trachea.

Postresuscitation Interventions ThatImprove Neurological Outcomes (Circulation, pages I-326 to I-331)

New or Reaffirmed (1) Maintain normal ventilation

(Class IIa) without hyperventilation (Class III). (2) Monitor

temperature, treat hyperthermia (Class IIa for the patient with

head injury or reduced cardiac output); allow mild hypothermia

(Class IIb). (3) Manage post–ischemic myocardial dysfunction

(no class given, no evidence reviewed). (4) Maintain normal

glucose levels (no class given; this was not a topic in the

postresuscitation panel but is a reaffirmation of 1992 Guidelines).

Old Previous guidelines recommended hyperventilation,

failed to comment on hyperthermia or hypothermia, and

recommended that clinicians normalize serum glucose and

avoid hyperglycemia.

Why? Hyperventilation reduces cerebral blood flow

and may create cerebral ischemia, so it should not be used

routinely. Some evidence suggests that mild hypothermia

reduces damage from an ischemic insult, particularly when

the hypothermia precedes the insult. This “protective”

effect of hypothermia on the brain and organs is under

investigation. Hyperthermia increases oxygen demand and

should be corrected. Hyperglycemia or hypoglycemia or

both can have detrimental effects.

Laryngeal Mask Airway: AnAlternative, Advanced Airway Device(Circulation, page I-297)

New Laryngeal mask airways (LMAs) can be used to secure

an airway in an unconscious patient. They are used widely in the

operating room and provide an effective means of ventilation and

oxygenation in unconscious patients. With proper training and

supervision, they can be placed safely and reliably in infants and

children (Class Indeterminate for use in cardiac arrest).

Old LMAs were not approved for use in the United States

in 1992.

Why? Ventilation with the LMA appears to be clinically

equivalent to ventilation with a tracheal tube. Placement of

tracheal tubes appears to have a much higher risk for causing

harm to the victim in the prehospital setting. Mastery of

LMA insertion, at least in adults, is simpler than mastery of

tracheal intubation. Pediatric tracheal intubation is a difficult

skill that requires extensive training as well as frequent prac-

tice to maintain expertise. The complication rate for prehos-

pital tracheal intubation is high. Therefore, if physiologically


equivalent alternative airway devices can be placed with a

high success/low complication rate, their use is acceptable.

Intraosseous Route Acceptableand Recommended to IncludeVictims 6 Years of Age or Older(Circulation, page I-305)

New The age range within which intraosseous access is

acceptable and recommended is extended to all victims

including children over the age of 6 years. There is no upper

age limit.

New When healthcare personnel are unable to achieve

vascular access in pediatric emergencies within a reasonable

time, intraosseous access is acceptable and recommended.

“Reasonable” depends on the condition of the patient—PALS

uses the 90-second suggested limit for establishment of vascular

access in cardiac arrest but offers a little more flexibility if the

patient is stable (Class IIa).

Old In children 6 years of age or younger, intraosseous

vascular access should be established if reliable venous access

cannot be achieved within 3 attempts or 90 seconds, whichever

comes first.

Why? Access to the circulation is critical and lifesaving

for drug and fluid administration to the pediatric patient, although

it is often difficult to achieve. Successful use of intraosseous

access has been documented in patients well beyond 6 years of

age and can be achieved routinely within 30 to 60 seconds. The

success rate for intraosseous cannulation is lower for older chil-

dren than it is for younger children, but it still provides a reason-

able alternative when vascular access cannot be achieved in a

timely manner.

Vagal Maneuvers Added to theTreatment Algorithm forSupraventricular Tachycardia(Circulation, pages I-314 to I-315)

New Vagal maneuvers are recommended for the treatment of

supraventricular tachycardia, provided these maneuvers do not

delay cardioversion or use of adenosine for the child with poor

systemic perfusion. Ice water applied to the face is most effective

in infants and young children (Class IIb).

Old Vagal maneuvers were not mentioned.

Why? Evidence shows that vagal maneuvers can terminate

supraventricular tachycardia. In children with milder symptoms,

vagal maneuvers may be attempted during preparation for

cardioversion or drug therapy, provided the child is hemo-

dynamically stable. Success rates with these maneuvers are

variable and depend on underlying conditions, the patient’s

level of cooperation, and the patient’s age.

Amiodarone Added to thePediatric Treatment Algorithmsfor Supraventricular and VentricularTachycardia and VF/VT New Amiodarone can be used for both supraventricular and

ventricular arrhythmias; in particular, amiodarone may be

considered for refractory VF that persists despite 3 shocks.


Old Intravenous forms of amiodarone were not approved for

use until the late 1990s.

Why? Amiodarone has been used most commonly in children

in the postoperative period after cardiac surgery. Amiodarone

is effective on ectopic atrial tachycardia or junctional ectopic

tachycardia.

Amiodarone is also effective for VT in postoperative patients

or children with underlying cardiac disease. Successful expe-

rience with this drug in children continues to accumulate.

There are no prospective, randomized trials of amiodarone in

pediatric cardiac arrest.

Amiodarone has been added as a drug to consider in pediatric

pulseless arrest on the basis of evidence extrapolated from adult

prospective, clinical trials. In a large, prospective, randomized

trial in adults, amiodarone was associated with a significant

increase in the rate of admission to hospital but not survival rate

for adults with shock-refractory VF/pulseless VT. For ease of

learning, PALS and ACLS algorithms attempt to achieve


consistency. Therefore, despite little evidence about amiodarone

in the specific setting of pediatric pulseless arrest, amiodarone

enters the pediatric algorithms (Class Indeterminate).

Use of High-Dose EpinephrineDe-emphasizedNew High-dose epinephrine for pulseless arrest is

de-emphasized in pediatrics. The recommended initial

resuscitation dose of epinephrine for pediatric cardiac arrest

is 0.01 mg/kg, given by the intravenous or intraosseous route

or 0.1 mg/kg by the tracheal route. Repeated doses are

recommended every 3 to 5 minutes for ongoing arrest. The

same dose of epinephrine is recommended for second and

subsequent doses for unresponsive asystolic and pulseless

arrest, but higher doses of epinephrine (0.1 to 0.2 mg/kg)

by any intravascular route may be considered (Class IIb).


Old The 1992 Guidelines recommended higher doses of epi-

nephrine for second and subsequent doses as Class IIa.

Why? High doses of epinephrine (HDE) improve myocardial

and cerebral blood flow in animals with cardiac arrest. High res-

cue doses of epinephrine were associated with improved survival

rates and neurological outcome compared with historic controls

in a single, nonblinded clinical trial of 20 children with witnessed

cardiac arrest. Large multi-institutional adult studies, well-con-

trolled animal studies, and uncontrolled, retrospective pediatric

data failed to show benefit from HDE. HDE can have adverse

effects including increased myocardial oxygen demand, hyper-

adrenergic state, tachycardia, hypertension, and myocardial

necrosis. There is great interpatient variability in dose response.

It is possible that a dose dangerous for one patient may be

lifesaving for another.

Automated External Defibrillators forTreatment of Children ≥8 Years of AgeNew AEDs may be used in the treatment of children with

out-of-hospital cardiac arrest who are more than 8 years of age.

Attempts to defibrillate VF/pulseless VT detected by an AED

are acceptable and recommended for children ≥8 years of age,

particularly in the out-of-hospital setting (Class IIb).


Old 1992 PBLS and PALS guidelines did not mention use of

AEDs in children. The ACLS textbook recommended their use

in children ≥8 years of age in 1994, and the PALS 1997 text rec-

ommended their use in children ≥8 years of age.

Why? Evidence continues to accumulate that pediatric VF

may be more common than previously suspected and more

common than would be identified by the usual surveillance

methods of emergency medical systems. Early defibrillation

of this VF/pulseless VT is important. Limited data suggests

that AEDs are both sensitive and specific in interpreting

rhythms in older children and adolescents. In children ≥8

years of age, the median weight should be >25 kg, so a 150-J

biphasic shock would deliver no more than 6 J/kg to a child

of average size who is at least 8 years of age. A monophasic

AED defibrillator with escalating shocks would initially

deliver 8 J/kg (200-J initial shock) and could increase to

14 J/kg if a 360-J dose is delivered to a 25-kg child. The

potential for harm from energy levels much greater than the

recommended upper limit of 4 J/kg causes great concern.

This high-energy level is acceptable only until AED

manufacturers develop AEDs with pediatric-appropriate

algorithms and energy levels.

2 Thumb–Encircling HandsTechnique for Chest Compression—See next page.


NeonatalResuscitation

Importance of Ventilation inthe Newly Born Infant

Reaffirmed In the newly born infant with heart rate

<100 beats per minute (bpm) and unresponsiveness to

stimulation, the primary concern is to establish adequate

ventilation. (Circulation,page I-350)

Interventions Revised forNeonates With Meconium-StainedAmniotic Fluid

New When meconium is observed in amniotic fluid,

deliver the head and suction meconium from the hypopharynx.

When meconium is observed in amniotic fluid and the newly

born infant demonstrates any of the following: (1) absent or

depressed respirations, (2) heart rate <100 bpm, or (3) poor

muscle tone, direct tracheal suctioning is recommended

(Class I) (Circulation,page I-348). Note that this eliminates

the recommendation for direct tracheal suctioning of the

meconium-stained but vigorous infant, whether the meconi-

um is thick or thin.

Old Direct endotracheal suctioning, using the tracheal tube

as a suction catheter, should be performed if the neonate is

depressed or the meconium is thick or particulate. Tracheal suc-

tioning may not be necessary if the meconium is thin and the

newborn is vigorous.

Why? Some neonates with meconium-stained amniotic

fluid have meconium in the trachea despite suctioning and in

the absence of spontaneous respiration. This suggests meconium

aspiration in utero. A recent randomized clinical trial demonstrated

that tracheal suctioning does not improve outcome and may

cause complications if the infant is active and vigorous.

Indications for ChestCompressions SimplifiedNew Start chest compressions (1) if the heart rate is absent

or (2) if the heart rate remains <60 bpm after 30 seconds of

adequate assisted ventilation. (Circulation,page I-351)

Old Start chest compressions (1) if the heart rate is <60 bpm or

(2) if the heart rate remains 60 to 80 bpm after 30 seconds of

adequate assisted ventilation with 100% oxygen.

New Judging chest compression depth: Use a relative gauge

for chest compressions depth, sufficient to generate a palpable

pulse OR about one third of the anterior-posterior depth of the

chest. Do not use an absolute gauge for chest compression depth.


Reaffirmed Coordinate chest compressions with

ventilation at a ratio of 3:1 with a rate of 120 events/minute

(90 chest compressions and 30 ventilations).

Why? Previous recommendations were complex and difficult

to remember. These simplified guidelines still emphasize the

need for adequate ventilation, which should be provided if the

heart rate is low. Always focus on ventilation and add chest com-

pressions when the heart rate is extremely low (<60 bpm).

Chest Compressions With 2 Thumbsand Encircling FingersThe Preferred Method for 2-RescuerHealthcare Providers

New Compressions should be delivered on the lower third of

the sternum. Acceptable techniques include the 2 thumb–encircling

hands technique and the 2-finger compression technique. The

2 thumb–encircling hands technique is preferred.


Old There are 2 techniques for performing chest compression

in the neonate. Both should be taught. In the preferred technique,

the 2 thumbs are placed on the middle third of the sternum with

the fingers encircling the chest and supporting the back.

Why? Data suggests that the 2 thumb–encircling hands

technique generates higher peak systolic and coronary perfusion

pressures and that providers prefer 2 thumbs with encircling

hands over the 2-finger technique.

Cautions Regarding Need for RescuerSkill in Endotracheal Intubation New Indications for endotracheal intubation can occur at sev-

eral points during neonatal resuscitation. The timing of endotra-

cheal intubation often depends on the skill and experience of the

rescuer. (Circulation,page I-351)

Old Endotracheal intubation was considered the gold

standardwhen advanced airway management was indicated.

The 1992 Guidelines contained no reference to rescuer skill,

rescuer experience, or the need for continued skill maintenance,

continued practice, and in-field experience. The need for

objective assessment of initial competence and objective

assessment of skills over time was not mentioned.


Why? Several reports document a high incidence of both

initial esophageal intubations (tube misplacement) as well

as subsequent tube dislodgments, when seriously ill or

injured children are intubated by providers inexperienced

in the technique. Proper bag-mask ventilation can provide

effective ventilation, particularly for short periods.

New Airway Adjunct—the Laryngeal Mask Airway (LMA)Now Available and Acceptable for Use but Only byAppropriately Trained Providers

New Masks that fit over the laryngeal inlet have been shown

to be effective for ventilating newly born full-term infants. The

LMA, when used by appropriately trained providers, shows

promise as an effective alternative for establishing an airway

in the newly born infant. This is especially true in the case of

ineffective bag-mask ventilation or failed endotracheal intubation

(Class Indeterminate). (Circulation,page I-350)

Old The LMA was not available for clinical use until the

late 1990s.

Why? See previous guideline. Note that the LMA is not

recommended routinely and it should not replace the endotracheal

tube for use in neonates with meconium-stained amniotic fluid.

Recommendations forSecondary Confirmation ofTracheal Tube Placement New An exhaled-CO2 monitor is one of several secondary

confirmation devices that should be used to verify tracheal

tube placement. These devices are associated with some

false-negative results (may lead to removal of a properly

placed tube), but few false-positive results (infrequently lead

to thinking an esophageal intubation is in the correct location).

Monitoring of exhaled CO2 can be useful in the secondary

confirmation of tracheal intubation in the newly born, particularly

when clinical assessment is equivocal (Class Indeterminate).


Old Confirmation of tracheal tube placement is accomplished

by clinical assessment, with no mention of use of exhaled

CO2 for secondary confirmation.

Why? Intubation of the small infant can be difficult,

particularly if the rescuer is inexperienced. Several reports

have documented a significant incidence of undetected tube

misplacement or tube dislodgment following intubation of

seriously ill or injured children in the prehospital setting.

Secondary confirmation reduces the risk of undetected tube

misplacement, and continued use of these confirmation

techniques provides early recognition of tube dislodgment.

Caution should be used when applying this technique in

the setting of pulseless arrest or on infants less than 2 kg.


Use of Crystalloid Solutions for InitialVolume Resuscitation Instead ofAlbumin-Containing SolutionsNew The fluid of choice for volume expansion is an isotonic

crystalloid solution such as normal saline or Ringer’s lactate

(Class IIb). Administration of O-negative red blood cells may be

indicated for replacement of large-volume blood loss. Albumin-

containing solutions are less frequently used for initial volume

expansion. (Circulation, page I-352)

Old Blood volume expansion may be accomplished by

using 10 mL/kg of (1) normal saline or Ringer’s lactate,

(2) 5% albumin-saline or other plasma substitute, or

(3) O-negative blood cross-matched with the mother’s blood.

Why? Albumin-containing solutions are less frequently used

because of limited availability, a potential for risk of infectious

disease, and an observed association with increased mortality.

Ethical IssuesNew There are circumstances in which noninitiation or dis-

continuation of resuscitation in the delivery room may be appro-

priate. Specific situations are suggested in the guidelines (eg,

infants with confirmed gestation <23 weeks or birthweight

<400 g, anencephaly, or confirmed trisomy 13 or 18).


Old No mention of noninitiation of resuscitation in the chapter

on neonatal resuscitation; brief discussion in ethics chapter.

Why? Considerable evidence now documents the long-term

outcomes of a large number of premature, small, or impaired

infants following delivery resuscitation. Such information pro-

vides data to support discussions with parents, family members,

and staff about not starting or early discontinuation of resuscita-

tion attempts.

Hypothermia and ResuscitationNew Recent animal and human studies have suggested that

selective (cerebral) hypothermia of the asphyxiated infant may

protect against brain injury. This approach cannot be recom-

mended routinely until appropriate controlled studies in

humans have been performed (Class Indeterminate).



Old All newborns have difficulty tolerating a cold

environment. Asphyxiated neonates have a particularly

unstable thermoregulatory system, and recovery from

acidosis is delayed by hypothermia.

Why? This is not a change but a qualification in anticipa-

tion of new information becoming available during the next

several years. It is designed to alert providers about a promis-

ing area of research.

Prevent HyperthermiaNew Avoid hyperthermia, since it can be associated with

perinatal respiratory depression (Class III). (Circulation,page

I-348)

Old No mention of hyperthermia, only of prevention of

heat loss.

Why? New data (1999 publications) linking respiratory

depression with hyperthermia (particularly associated with

maternal fever) has been reported.

Neonatal Guidelines Reviewedand Reaffirmed• Personnel capable of initiating resuscitation should attend

every delivery. (Circulation,page I-345)

• Use 100% oxygen if assisted ventilation is required. There is

insufficient data to justify a change in this recommendation.


Advanced CardiacLife Support

Changes in the ACLS Algorithms For the benefit of experienced ACLS instructors and

providers, explanation of the major guideline changes and

revisions uses the new algorithms as an organizing focal

point. The new algorithms are contained in the special

Circulation supplement containing the full guidelines

(August 22, 2000) and the 2000 ECC Handbook.

Figure 1: ILCOR Universal AlgorithmThe international resuscitation community outside the United

States prefers simple, sparse teaching aids, with the items listed

representing just a hint of the unseen details. For example, the

box labeled “Universal algorithm” is really a representation of all

the actions and details implied by that step. All 4 cardiac arrest

conditions (VF, pulseless VT, asystole, and pulseless electrical

activity) are covered in this one algorithm. Because many learners

may prefer the simple, uncluttered overview to assist learning,

the Universal ILCOR algorithm is retained.

Figure 2: Comprehensive ECC CardiacArrest AlgorithmThis is the AHA ECC version of the ILCOR Universal algo-

rithm, once again providing guidelines for all 4 cardiac arrest

conditions. This algorithm also introduces the Primary and

Secondary ABCD Surveys as a way to organize the rescuers’

thoughts, action sequences, and anticipations. A fair percentage

of the total new ACLS guideline changes are either displayed or

hinted at in this algorithm, especially in Figure 3.

Figure 3: Ventricular Fibrillation/PulselessVentricular TachycardiaThis algorithm conveys most of the important new guideline

changes. The listing of items by “box number” refers to the

VF/pulseless VT algorithm.

Box 1: Primary ABCD Survey This algorithm adheres to the “phone first” action sequence in

which the witness activates the 911-EMS system response. This

is based on an awareness of the high frequency of VF—“get the

defibrillator to the VF patient as fast as possible!”

New The International Guidelines 2000 recommend

changing the treatment sequence if the rescuer possesses

acute knowledge of a non-VF cause for the collapse

(Circulation,page I-147). If the cause of the collapse is NOT

VF/pulseless VT, then the victim is more in need of the

primary ABCs (open airway; check for breathing, provide

rescue breaths; check for signs of life, start chest compressions)

with 1 minute of CPR, in the following situations:

• Submersion/near-drowning (1 minute CPR; then “phone fast”)

• Poisoning, drug overdoses (1 minute CPR; then “phone fast”)

• Trauma (1 minute CPR; then “phone fast”)

• Respiratory arrest (1 minute CPR; then “phone fast”)

Note the simple reference to defibrillators that use biphasic

waveforms. Lack of escalating energy levels by some brands

of AEDs is of little concern as long as the particular wave-

form has been shown to be equivalent in clinical effective-

ness to the monophasic waveform devices.

Box 2: Secondary ABCD SurveyThe major new recommendations regarding management of the

airway, ventilation, and oxygenation are covered in this

Secondary ABCD Survey.


1. Place airway device as soon as possible. Two new advanced

airway devices that are recommended as equivalent to the

tracheal tube—the laryngeal mask airway and the Combitube—

do not enter the “endo-tracheal” area, but rather each device is

placed in the hypopharyngeal region, outside of the vocal cords.


2. Confirm airway device placement by primary confirmation

(physical exam) plus secondary confirmation (using a device).

Primary and secondary confirmation of airway device placement

is discussed in other sections.

Box 3: Intravascular Epinephrine 1 mg(Class Indeterminate) OR Vasopressin40 U for Refractory VF/Pulseless VT

New The most effective adult dose of epinephrine remains

1 mg every 3 to 5 minutes After this point, the nomenclature

and dosing of epinephrine quickly become confusing and

contradictory. For example, high-dose epinephrine = 0.1 mg/kg

to 0.2 mg/kg; escalating doses of epinephrine = 1 mg, 3 mg,

5 mg; intermediate dose of epinephrine = 5 mg IV. Some experts

make distinctions between using high-dose epinephrine as the

initial dose or for later doses. In addition, many consider

cumulative doses of epinephrine over the course of the

resuscitation to be more important than single high doses.

New Higher doses of epinephrine are suspected of

causing harm.

Research has not yet demonstrated that routine use of initial 1-mg

doses combined with repeated/escalating doses of epinephrine

can improve survival in cardiac arrest (Class Indeterminate).

Multiple trials of high-dose versus standard-dose epinephrine

as the initial dose given have confirmed that epinephrine

1 mg IV was just as effective as any higher dose.

Since 1992, however, some studies noted that higher-dose or

high-dose epinephrine was associated with worse neurologic

outcomes in those patients who were resuscitated. This trouble-

some evidence suggests that arrest survivors who had received

high-dose epinephrine had more postresuscitation complications

than survivors who had received the standard dose.

High-dose epinephrine remains an acceptable approach, but only

after epinephrine 1 mg has failed (Class IIb). The “barely

acceptable”classification came only because of some studies

in which it was associated with higher resuscitation and

admission rates but not better long-term or neurologically intact

survival. Many experts suggested a Class III recommendation for

all higher doses of epinephrine. The conclusion was to give

higher-dose epinephrine a Class IIb status, meaning its use

was acceptable but no longer recommended. Clinicians who

routinely use high/higher-dose epinephrine should abandon

that practice, saving the higher doses only for cases in which

specific reasons justify the use of an agent with potential for

both benefit and harm.

VasopressinNew Vasopressin is equivalent to epinephrine for

refractory VF/pulseless VT. The initial vasopressor agent for

refractory VF/pulseless VT can be either epinephrine

(Class Indeterminate) or vasopressin (Class IIb). As a

vasoconstrictor, vasopressin appears as effective as epinephrine,

with fewer negative effects on the heart. Despite decades of

use, the effectiveness of epinephrine in human cardiac arrest

has not been shown in prospective, randomized human

clinical trials. (Circulation,page I-146)

Vasopressin lasts much longer (10 to 20 minutes); therefore, only

1 dose is recommended. By consensus, epinephrine 1 mg every 3

to 5 minutes can be resumed after 5 to 10 minutes of no

response to the vasopressin. There is little evidence on this

topic. Deliver the 4th shock 30 to 60 seconds after either epi-

nephrine or vasopressin.

Box 4: Consider Antiarrhythmicsand Buffers

AmiodaroneNew Amiodarone is added to the list of antiarrhythmics

to consider for shock-refractory VF/pulseless VT (Class IIb).

The alternative antiarrhythmic at this point in the algorithm is

lidocaine (Class Indeterminate). (Circulation,page I-149)

Amiodarone requires several time-consuming steps before

administration: a glass ampule must be opened, the drug aspirat-

ed into a syringe with a large-gauge needle and reconstituted

with NS, the needle changed, and then the drug administered

slowly through the IV line. These steps take time. Administration

of amiodarone must NOT delay the 4th or even 5th shock or sub-

sequent epinephrine doses. Instructors should become very familiarwith the guidelines recommendations.

BretyliumNew Bretylium, because of supply problems and a high

incidence of side effects, will no longer be included in the ACLS

list of recommended antiarrhythmics.


LidocaineNew Lidocaine remains acceptable for the treatment of

shock-refractory VF, but the levels of evidence supporting a

strong role for lidocaine are at best levels 6, 7, and 8. The

conference conclusions therefore were that lidocaine should

continue to be listed in the algorithm for VF/VT but with an

Indeterminate Class of Recommendation. Lidocaine has not

been recommended for routine prophylaxis of ventricular

arrhythmias in the setting of acute myocardial infarction for

more than 8 years. Conference experts reexamined this ques-

tion and reported that no significant data has accumulated

since 1992 to change the classification of lidocaine to a Class

III (evidence of harm) agent. (Circulation,page I-149)

Magnesium has demonstrated effectiveness for treatment of

VF/pulseless VT in 2 clinical situations: (1) torsades de

pointes, for which it still has a Class IIb recommendation and

(2) VF/VT and other arrhythmias associated with known

hypomagnesemia (Class IIb).

Figure 4: Pulseless Electrical Activity

New The PEA algorithm contains all of the new guide-

lines discussed above in the VF/VT algorithm including tra-

cheal tube insertion, verification of proper tube placement,

epinephrine, and atropine. Note that vasopressin does not

appear in any algorithm other than VF/VT (Class

Indeterminate). (Circulation,page I-150)

Figure 5: Asystole

New The asystole algorithm contains few new clinical rec-

ommendations in terms of the epinephrine, atropine, and pac-

ing that have been the only 3 interventions used for

asystole for more than a decade. Many experts, however,

consider this algorithm to contain the most significant and

important new guidelines changes. (Circulation,page I-152)

New Healthcare providers are advised to specifically

survey the resuscitation scene for a living will, advance

directive, or no-CPR bracelet or anklet and to be particularly

aware and sensitive that asystole often occurs in terminally

ill patients who are expecting to die. The 911 call does not

mean the family or patient has changed the decision to

forego or renounce a no-CPR decision. The call most often

means the patient or family is uncomfortable with death at

home; support, information, and conscientious efforts to

make the patient as comfortable as possible are needed.


New Relatively specific criteria are listed in the algorithm

and in the notes for withholding or stopping resuscitation

efforts. These criteria direct the resuscitation team to consider

the quality of the resuscitation, whether unusual clinical fea-

tures might be present, and whether cease-effort protocols

have been developed and are in place. (Circulation,page I-154)

New Protocols for leaving the body at the scene. The

algorithm notes and the ECC textbook discuss the steps

necessary to adopt these important new protocols for leaving

the body at the scene, including designating an EMS person

designated

to care for the family and survivors and establishing who to

call for completion of death certification documents.


Figure 6: Bradycardias

Reviewed and Reaffirmed Unlike the tachycardia

algorithms, in which massive changes, revisions, and new agents

now appear, clinical research has not identified the need for new

guidelines for bradycardias. The existing intervention sequence

of atropine, transcutaneous pacing, dopamine, and epinephrine

remains intact and unmodified. (Circulation,page I-155)

Figure 7: Tachycardia Overview Plus Wide-Complex TachycardiasTable 7B: Control of Rate and Rhythm inAtrial Fibrillation and FlutterFigure 8: Narrow-ComplexSupraventricular TachycardiasFigure 9: Ventricular Tachycardias Thatare Stable

The most critical new guidelines for the management of

tachycardias are several important management principles:

New Cardiologists who specialize in treatment of arrhythmias

helped develop the new algorithms for tachycardias

(Circulation,page I-158). Proper treatment of tachyarrhythmias

is complicated. ACLS providers can best serve their patients

by understanding and practicing 5 new perspectives on the

ACLS guidelines:

1. Antiarrhythmics are also proarrhythmics. All antiarrhyth-

mic agents are now recognized to possess some degree of

proarrhythmic activity.

2. The use of more than 1 antiarrhythmic to treat tachycardia is

undesirable because it increases the risk of complications.

Administration of more than 1 antiarrhythmic during treatment

of an episode of tachycardia is not routinely recommended.

3. If the patient has impaired myocardial function, most antiar-

rhythmics will make cardiac function worse. Selection of the


optimal antiarrhythmic for a given circumstance often requires

knowledge of the patient’s underlying ventricular function.

4. Consider electrical cardioversion as either the intervention

of choice or the second antiarrhythmic. The decision threshold

for performing electrical cardioversion should be much lower

than previously thought. In the “stable versus unstable” deci-

sion, consider this rule of thumb: when an antiarrhythmic is

administered to a patient with persistent tachycardia, that

agent, by definition, renders that patient “unstable.”

5. There is now a much higher priority on arriving at a spe-

cific diagnosis, if time permits, in the acute setting.

New New drugs have been suggested for use for atrial fib-

rillation with class of recommendation dependent on specific

resuscitation circumstance: amiodarone, flecainide,

propafenone, sotalol, ibutilide.

New The hemodynamically stable VT algorithm shows

how rhythm diagnosis is critical and offers a means to an

accurate and specific assessment of whether the patient has

impaired heart function or early congestive heart failure.

Brief Summary of the TachycardiasAlgorithms

New agents and new approaches have been developed to

make treatment of the tachycardias accurate, safe, and

effective (Circulation,page I-159 to I-163)

Atrial Fibrillation and Flutter

New The table summarizes the major treatment considera-

tions for atrial fibrillation and flutter:

• Is the patient clinically unstable?

• Is cardiac function impaired?

• Is Wolff-Parkinson-White syndrome present?

• Has the duration of the atrial fibrillation been >48 hours?

New The treatment is staged depending on several factors:

1. If patient is unstable, cardiovert at once.

2. First control the rate.

3. Then convert the rhythm.

Narrow-Complex SupraventricularTachycardia

New Adenosine still begins the treatment for these

rhythms, but rhythms must then be sorted into junctional

tachycardia versus paroxysmal supraventricular tachycardia

versus multifocal atrial tachycardia.

New Each subset of the supraventricular tachycardia must then

be sorted by preserved cardiac function versus impaired function.

Stable Ventricular Tachycardias

New Treatment depends on whether the VT is polymorphic or

monomorphic and stable or unstable; treatment of polymor-

phic depends on whether the patient has normal or prolonged

QT intervals.

New Amiodarone is the drug of choice for stable ventricu-

lar tachycardia; procainamide is the drug of second choice.

Old Lidocaine was the familiar agent recommended first

for stable wide-complex tachycardias.

Stable Wide-Complex Ventricular Tachycardia

New Amiodarone and sotalol (IV form not yet approved

in the United States) are the drugs of first choice for

wide-complex ventricular tachycardia.

Acute Coronary Syndromes(Circulation, page I-172)

New The prehospital 12-lead ECG should become stan-

dard equipment on all ACLS units that handle acute coronary

syndrome patients (Class IIa).

New Prehospital fibrinolytic therapy is beneficial when

transport time of acutely “infarcting patients” from their

home to the hospital is prolonged (60 minutes or longer).

New Angioplasty is an alternative to fibrinolytic therapy

(Class I) in centers with high volume and experienced operators.

New Patients in cardiogenic shock who are <75 years of

age should be transported to interventional centers for con-

sideration of primary angioplasty and intra-aortic balloon

placement when these centers are experienced and door-to-

balloon times average 90 minutes or less (Class I).

New Patients who are not eligible for fibrinolytic therapy

due to exclusionary criteria should be considered for trans-

port or transfer to interventional centers (Class IIa). Patients

with large anterior infarctions, low blood pressure (SBP <100

mm Hg), and increased heart rate (>100 bpm), or rales >1/3

are also candidates for transfer (Class IIa).

New Antiplatelet therapy with glycoprotein IIb/IIIa

inhibitors for patients with non–Q-wave myocardial infarction

and high-risk unstable angina is recommended (Class IIa).

New Antithrombin therapy with low-molecular-weight

heparins is now an alternative agent for unfractionated

heparin in high-risk unstable angina/non–Q-wave MI, but


data for this class of agents is heterogeneous, in part due to

variable anti–factor Xa inhibition (Class Indeterminate).

New The weight-adjusted dose of unfractionated heparin

indicated as adjunct therapy with fibrin-specific lytics

(alteplase, reteplase) is now reduced to 60 U/kg (maximum

4000 U) bolus and 12 IU/kg/h infusion to minimize the inci-

dence of intracerebral hemorrhage with these agents.

New Metabolic manipulation of the infarct with glucose-

potassium-insulin is under continuing investigation. Infusion

of a clinically efficacious dose may be beneficial in diabetic

patients and in those undergoing reperfusion (Class IIb).

New All patients with acute myocardial infarction, including

non–Q-wave MI, should receive aspirin and ß-blockers in the

absence of contraindications (Class I). Patients with large

anterior infarction, left ventricular dysfunction, and ejection

fraction <40% should receive early ACE inhibition in the

absence of hypotension.

Stroke (Circulation, page I-204)

New Intravenous rtPA improves neurologic outcome

in patients with stroke meeting fibrinolytic criteria

when administered within 3 hours of onset (Class I).

New Stroke presenting within 3 hours should be

triaged on an emergent basis with urgency similar to

acute ST-elevation myocardial infarction.

New The use of rtPA in patients within more than 3 hours

but less than 6 hours of symptom onset is under investigation.

A subgroup of such patients may benefit, but use is not

presently recommended (Class Indeterminate).

New Prourokinase has been found to improve neurologic

outcome in patients treated within 3 to 6 hours in 1 complet-

ed but unpublished study. Review of the published data and

additional studies are needed before recommendation of this

fibrinolytic agent is recommended (Class Indeterminate).

New EMS systems should implement a prehospital stroke

protocol to evaluate and rapidly identify patients who may

benefit from fibrinolytic therapy, similar to the protocol for

chest pain patients (Class IIb).

New Patients who may be candidates for fibrinolytic ther-

apy should be transported to hospitals identified as capable

of providing acute stroke care, including 24-hour availability

of CT scan and interpretation (Class IIb).

Postresuscitation Care(Circulation, page I-166)

New Patients who are mildly hypothermic after cardiac

arrest should not be actively rewarmed (Class IIb).

New Active hypothermia after cardiac arrest is under

clinical investigation (Class Indeterminate).

New Febrile patients should be treated with antipyretics

(Class IIa).

New After cardiac arrest, patients who require mechanical

ventilation should have ventilatory parameters maintained in

the normal range (Class IIa).

New Hyperventilation may be harmful and should be avoided

(Class III). An exception is the use of hyperventilation in

patients who have signs of cerebral herniation after resuscitation.

Toxicology

CocaineCocaine use can be associated with serious ventricular

arrhythmias and acute coronary syndromes.

New ß-Blockers in this subset of patients with acute coro-

nary syndromes have been associated with coronary vasocon-

striction and should be avoided (Class III).

New Nitrates should be first-line therapy (Class I) as well

as benzodiazipines (Class IIa).

New α-Adrenergic blocking agents may induce tachycardia

and hypotension and should be reserved for patients who do

not respond to nitrates and benzodiazipines (Class IIb).

Tricyclic antidepressants

Hypotension or ventricular arrhythmias may occur in the set-

ting of tricyclic overdose.

New The induction of a systemic alkalosis with a pH

of 7.50 to 7.55 is the treatment of choice (Class IIa).

New The use of antiarrhythmic agents such as

lidocaine or procainamide has not been studied in

this setting (Class Indeterminate).


Opiate overdose

Acute respiratory failure (respiratory acidosis and hypox-

emia) may occur with opiate overdose.

New The expeditious reversal of these abnormalities by

mechanical ventilation before the administration of naloxone.

This reduces incidence of pulmonary edema and serious arrhyth-

mias associated with abrupt catecholamine elevation (Class IIa).

Circulatory and Ventilation/AirwayAdjuncts Approved for Clinical UseNew Laryngeal mask airway and the Combitube are better

alternatives for ventilation than prolonged use of the bag-

mask (Class IIa). (Circulation,page I-98)

New Active compression-decompression CPR (“plunger”

CPR) is an alternative to standard CPR for improving out-

comes when sufficient number of rescue personnel are ade-

quately trained in the use of this device (Class IIb).


New Interposed abdominal compression CPR for in-hos-

pital resuscitation is an alternative to standard CPR when

sufficient personnel trained in the technique are available

(Class IIb). (Circulation,page I-105)

New Vest CPR is an alternative for standard CPR for

hemodynamic support and short-term (6-hour) survival when

there are an adequate number of well-trained, in-hospital per-

sonnel to properly perform this technique (Class IIb).


New Mechanical (piston) CPR may provide hemodynamic

support comparable to standard manual CPR, can reduce rescuer

fatigue, and can be helpful in improving the quality of CPR in

situations where manual chest compressions are difficult (Class

IIb). (Circulation,page I-107)

New Direct cardiac massage CPR is an alternative tech-

nique for resuscitation, considered after initial attempts at

external chest compressions have failed and time of cardiac

arrest is still within the defined window of opportunity (<30

minutes) (Class IIb). (Circulation,page I-107)

New The impedance threshold valve enhances negative

thoracic pressure during the decompression phase of chest

compression with the the active compression-decompression

cardiopump. Early experience suggests some improvement in

hemodynamic and expired CO2 during CPR (Class IIb).


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