Oxford UK, and Dallas, TX - New guidelines for the resuscitation of adults and children are being issued in the US, Europe, and elsewhere as part of an international effort to establish best practice worldwide [1]. This is the first update of the recommendations in five years, and the most significant changes are to advise more chest compressions and to change the way in which compressions and defibrillation are used together.

The new advice is based on a comprehensive, evidence-based review of resuscitation science undertaken over the past two years by experts from all over the world and debated during a consensus meeting held in January in Dallas.

The new US guidelines are published online with an accompanying editorial in Circulation [2],and the recommendations from the European Resuscitation Council appear online in the journal Resuscitation [3], accompanied by a consensus on resuscitation science [4].

The new guidelines—which are basically identical—will also be accompanied by editorials in major medical journals such as the BMJ later this week, cochair of the International Liaison Committee on Resuscitation Dr Jerry Nolan (Royal United Hospital, Bath, UK) told heartwire.

Nolan says there are four main changes to previous advice.

First, the advice is to give more compressions during cardiopulmonary resuscitation (CPR) and relatively fewer ventilations. The 2005 guidelines recommend giving 30 chest compressions for every two breaths instead of the traditional 15 compressions for 2 breaths. This applies to both adults and children (with the exception of neonates), and it is hoped that this will be easy for people to remember. This is based on studies showing that circulating blood increases with each chest compression in a series and must be built back up after interruptions.

The second recommendation builds on this, advising that instead of administering three shocks in succession, as is the current practice, healthcare workers should give one shock only and then resume compressions for two minutes. Checks to heart rhythm, inserting airway devices, and administration of drugs should be done without delaying compressions. When the cycle of analysis, shock, and reanalysis is repeated three times before compressions, this results in a delay of half a minute or more before there are any compressions.

Tied to this is advice to administer adrenaline if the patient remains in ventricular fibrillation (VF). Nolan says this is one of the areas where there is a minor difference between the European and US guidelines, with the European advice being to give it before the third shock while the Americans advise that adrenaline can be used before the second shock. Regardless of when it is first given, adrenaline should be repeated every three to five minutes if the patient remains in VF, he adds.

The third change is part of "the continued emphasis on trying not to interrupt compressions," says Nolan, emphasizing "that even delays of 10 to 20 seconds can reduce the chance of a successful defibrillation." Accordingly, the advice is to reduce the time involved in mouth-to-mouth resuscitation so that breathing into a patient is reduced from two seconds to one, again leaving more time for compressions.

Finally, for paramedics attending to a cardiac arrest in the field, the advice has always been to "shock as soon as possible," says Nolan. But the new guidelines advocate a few minutes of compressions before shocking, "which gives a better chance of a successful defibrillation," he notes.

Other changes include training dispatchers to recognize symptoms of acute coronary syndrome and advise patients without a history of gastrointestinal bleeding to chew aspirin. Also, there are new recommendations to use therapeutic hypothermia in some patients admitted to intensive-care units after cardiac arrest and to use tPA "for carefully selected patients with ischemic stroke."

Nolan says that "thevast majority of healthcare professionals will be unaware of these new recommendations" and that it will be important to make sure the guidelines filter down to people. "Changes will be made in training and in advanced life-support courses, but when we can expect significant changes in hospital practices, I don't know."

He hopes that online publication of the new guidelines plus coverage in major medical journals will be the first step in disseminating the new advice.