IV-4 Circulation December 13. 2005 interruption of chest compressions. Recommendations for quality improvement to reduce time to CPR and shock pulse checks are during the treatment of pulseless delivery and to improve the quality of CPR provided 23.24 arrest(Parts 4. 5 The AHA and collaborating organizations will use these Recommendation I shock followed immediately by guidelines as the basis for developing comprehensive training CPR(beginning with chest compressions)instead of 3 materials. Once the training materials are available, the most stacked shocks for treatment of ventricular fibrillation/ important step will be to get them into the hands of rescuers pulseless ventricular tachycardia: this change is based on who will learn, remember, and perform CPR and ECC skills. the high first-shock success rate of new defibrillators and the knowledge that if the first shock fails, intervening che References compressions may improve oxygen and substrate delivery 1. Intemational liaison committee on resuscitation. 2005 Internat to the myocardium, making the subsequent shock more Consensus on Cardiopulmonary Resuscitation and Emergency Cardio- kely to result in defibrillation(Parts 5, 7. 2, and 12) ascular Care Science with Treatment Recommendations. Circulation 005:112Il-1-l-136 Increased emphasis on the importance of ventilation and 2. American Heart Association in collaboration with International Liaison de-emphasis on the importance of using high concentra- Committee on Resuscitation. Guidelines 2000 for Cardiopulmonary tions of oxygen for resuscitation of the newly born infant Resuscitation and Emergency Cardiovascular Care. Circulation. 2000; 102(suppl): Il-1384. (Part 13) 3. Standards for cardiopulmonary resuscitation(CPR) and Reaffirmation that intravenous administration of fibrinolyt- cardiac care(ECC). 3. Advanced life support. JAMA. 1974: 227: (suppl): ics(tPA) to patients with acute ischemic stroke who meet 852-860 4. Standards and guid ary resuscitation(CPR) and the NINDs eligibility criteria can improve outcome. The emergency cardiac care (ECC). JAMA. 1980: 244: 453-509. Pa should be administered by physicians in the setting of 5. Standards and guidelines for Cardiopulmonary Resuscitation(CPR)and a clearly defined protocol, a knowledgeable team, and mergency Cardiac Care (ECC). National Academy of Sciences- institutional commitment to stroke care(Part 9) 256:1727JAMA.1986;255:2905-2989 New first aid recommendations(Part 14) 6. Guidelines for cardiopulmonary resuscitation(CPR) and emergency cardiac care(ECC). JAMA. 1992: 286: 2135-2302 For further information about these and other new devel- Zaritsky A, Morley P. The evidence evaluation process for the 200 opments in these guidelines, see the editorial"The Major nternational consensus on cardiopulmonary resuscitation and emergency ardiovascular care science with treatment recommendations. Circu- Changes in the 2005 AHA Guidelines for Cardiopulmonary lation.2005:112:IIl-128-I-130 Resuscitation and Emergency Cardiovascular Care"12 in this 8. Davidoff F, DeAngelis CD, Drazen JM, Hoey J, Hojgaard L, Horton R, pplement and the guidelines sections noted. Kotzin S, Nicholls MG, Nylenna M, Overbeke AJ, Sox HC, Van Der The recommendations in the 2005 AHA Guidelines for Weyden MB. Wilkes MS. Sponsorship, authorship, and accountability Lancet.2001358:854-856 CPR and ECC confirm the safety and effectiveness of many 9. Choudhry NK, Stelfox HT, Detsky AS Relationships between authors of approaches, acknowledge that other approaches may not be clinical practice guidelines and the pharmaceutical industry. JAMA. 2002, optimal, and recommend new treatments that have undergone 287:612-617 10. Billi JE, Eigel B, Montgomery WH. Nadkami V, Hazinski MF. Man- evidence evaluation. These new recommendations do not agement of conflict of interest issues in the American Heart Association ly that care involving the use of earlier guidelines is ergency cardiovascular care committee activities 2000-2005. Circu- safe. In addition, it is important to note that these guide- lation.2005;112IV-204-V-205 lines will not apply to all rescuers and all victims in all Il. Billi JE, Zideman D, Eigel B, Nolan J, Montgomery WH, Nadkarni situations. The leader of a resuscitation attempt may need to American Heart Association (AHA). Conflict of adapt application of the guidelines to unique circumstances. before, during, and after the 2005 international consensus conference on cardiopulmonary resuscitation and emergency cardiovascular care science with treat recommendations. Circulation. 2005: 112.III Future directions 13l-II-132. The most important determinant of survival from sudden 12. Hazinski MF, Nadkami VM. Hickey RW, O'Connor R, Becker LW, cardiac arrest is the presence of a trained rescuer who is Zaritsy A The major changes in the 2005 AHA guidelines for cardiopul- ready, willing, able, and equipped to act. Although hypother nd emergency cardiovascular care. Circulatio la has recently been shown to improve survival to hospital 13. Hypothermia After Cardiac Arrest Study Group. Mild therapeutic hypo- discharge for selected victims of VF SCA, 3 most advanced hermia to improve the neurologic outcome after cardiac arrest. N Engl life support techniques have failed to improve outcome from JMed.2002:346:549-556 14. Stiell IG, Wells GA, Field B, Spaite Dw. Nesbitt LP, De Maio vJ, Nichol SCA4 or have only been shown to improve short-term G, Cousineau D, Blackburn J, Munkley D, Luinstra-Toohey L, Campeat survival(eg, to hospital admission). 5, I6 Any improvements resulting from advanced life support therapies are less sub- cardiac arrest. N Eng! Med. 2004: 351: 647-656PPont in oul-of-hospital stantial than the increases in survival rate reported from 15. Dorian P, Cass D, Schwartz B, Cooper R, Gelaznikas R, Barr A. Ami- odarone as compared with lidocaine for shock-resistant ventricular fibril- successful deployment of lay rescuer CPR and automated lation. N Engl J Med. 2002: 346: 884-890 external defibrillation programs in the community. 7-21 16. Kudenchu MK, Cummins RO, Doherty AM, Thus, our greatest challenge continues to be the improve- Fahrenbruch CE, Hallstrom AP, Murray WA, Olsufka M, Walsh T. Amiodarone for resuscitation after out-of-hospital cardiac arrest due to ment of lay rescuer education. We must increase access ventricular fibrillation. N Engl J Med. 1999: 341: 871-878. CPR education, increase effectiveness and efficiency of 17. Holmberg M, Holmberg S, Herlitz J Effect of bystander cardiopulmonary instruction, improve skills retention, and reduce barriers to suscitation in out-of-hospital cardiac arrest patients in Sweden. Resus action for basic and advanced life support providers. 22 Re- cornton.200047:59-70. 8. Caffrey SL, Willoughby PJ, Pepe PE, Becker LB. Public use of suscitation programs must establish processes for continuous automated external defibrillators. N Engl J Med. 2002: 347: 1242-124interruption of chest compressions. Recommendations for pulse checks are limited during the treatment of pulseless arrest (Parts 4, 5, 7.2, 11, and 12). ● Recommendation of only 1 shock followed immediately by CPR (beginning with chest compressions) instead of 3 stacked shocks for treatment of ventricular fibrillation/ pulseless ventricular tachycardia: this change is based on the high first-shock success rate of new defibrillators and the knowledge that if the first shock fails, intervening chest compressions may improve oxygen and substrate delivery to the myocardium, making the subsequent shock more likely to result in defibrillation (Parts 5, 7.2, and 12). ● Increased emphasis on the importance of ventilation and de-emphasis on the importance of using high concentra￾tions of oxygen for resuscitation of the newly born infant (Part 13). ● Reaffirmation that intravenous administration of fibrinolyt￾ics (tPA) to patients with acute ischemic stroke who meet the NINDS eligibility criteria can improve outcome. The tPA should be administered by physicians in the setting of a clearly defined protocol, a knowledgeable team, and institutional commitment to stroke care (Part 9). ● New first aid recommendations (Part 14). For further information about these and other new devel￾opments in these guidelines, see the editorial “The Major Changes in the 2005 AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care”12 in this supplement and the guidelines sections noted. The recommendations in the 2005 AHA Guidelines for CPR and ECC confirm the safety and effectiveness of many approaches, acknowledge that other approaches may not be optimal, and recommend new treatments that have undergone evidence evaluation. These new recommendations do not imply that care involving the use of earlier guidelines is unsafe. In addition, it is important to note that these guide￾lines will not apply to all rescuers and all victims in all situations. The leader of a resuscitation attempt may need to adapt application of the guidelines to unique circumstances. Future Directions The most important determinant of survival from sudden cardiac arrest is the presence of a trained rescuer who is ready, willing, able, and equipped to act. Although hypother￾mia has recently been shown to improve survival to hospital discharge for selected victims of VF SCA,13 most advanced life support techniques have failed to improve outcome from SCA14 or have only been shown to improve short-term survival (eg, to hospital admission).15,16 Any improvements resulting from advanced life support therapies are less sub￾stantial than the increases in survival rate reported from successful deployment of lay rescuer CPR and automated external defibrillation programs in the community.17–21 Thus, our greatest challenge continues to be the improve￾ment of lay rescuer education. We must increase access to CPR education, increase effectiveness and efficiency of instruction, improve skills retention, and reduce barriers to action for basic and advanced life support providers.22 Re￾suscitation programs must establish processes for continuous quality improvement to reduce time to CPR and shock delivery and to improve the quality of CPR provided.23,24 The AHA and collaborating organizations will use these guidelines as the basis for developing comprehensive training materials. Once the training materials are available, the most important step will be to get them into the hands of rescuers who will learn, remember, and perform CPR and ECC skills. References 1. International Liaison Committee on Resuscitation. 2005 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardio￾vascular Care Science With Treatment Recommendations. Circulation. 2005;112:III-1–III-136. 2. American Heart Association in collaboration with International Liaison Committee on Resuscitation. Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2000; 102(suppl):I1–I384. 3. Standards for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC). 3. Advanced life support. JAMA. 1974;227:(suppl): 852– 860. 4. Standards and guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC). JAMA. 1980;244:453–509. 5. Standards and guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care (ECC). National Academy of Sciences— National Research Council [published correction appears in JAMA. 1986; 256:1727]. JAMA. 1986;255:2905–2989. 6. Guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC). JAMA. 1992;286:2135–2302. 7. Zaritsky A, Morley P. The evidence evaluation process for the 2005 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Circu￾lation. 2005;112:III-128 –III-130. 8. Davidoff F, DeAngelis CD, Drazen JM, Hoey J, Hojgaard L, Horton R, Kotzin S, Nicholls MG, Nylenna M, Overbeke AJ, Sox HC, Van Der Weyden MB, Wilkes MS. Sponsorship, authorship, and accountability. Lancet. 2001;358:854 – 856. 9. Choudhry NK, Stelfox HT, Detsky AS. Relationships between authors of clinical practice guidelines and the pharmaceutical industry. JAMA. 2002; 287:612– 617. 10. Billi JE, Eigel B, Montgomery WH, Nadkarni V, Hazinski MF. Man￾agement of conflict of interest issues in the American Heart Association emergency cardiovascular care committee activities 2000 –2005. Circu￾lation. 2005;112:IV-204 –IV-205. 11. Billi JE, Zideman D, Eigel B, Nolan J, Montgomery WH, Nadkarni V, from the International Liaison Committee on Resuscitation (ILCOR) and American Heart Association (AHA). Conflict of interest management before, during, and after the 2005 international consensus conference on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Circulation. 2005;112:III- 131–III-132. 12. Hazinski MF, Nadkarni VM, Hickey RW, O’Connor R, Becker LW, Zaritsy A. The major changes in the 2005 AHA guidelines for cardiopul￾monary resuscitation and emergency cardiovascular care. Circulation. 2005;112:IV-206 –IV-211. 13. Hypothermia After Cardiac Arrest Study Group. Mild therapeutic hypo￾thermia to improve the neurologic outcome after cardiac arrest. N Engl J Med. 2002;346:549 –556. 14. Stiell IG, Wells GA, Field B, Spaite DW, Nesbitt LP, De Maio VJ, Nichol G, Cousineau D, Blackburn J, Munkley D, Luinstra-Toohey L, Campeau T, Dagnone E, Lyver M. Advanced cardiac life support in out-of-hospital cardiac arrest. N Engl J Med. 2004;351:647– 656. 15. Dorian P, Cass D, Schwartz B, Cooper R, Gelaznikas R, Barr A. Ami￾odarone as compared with lidocaine for shock-resistant ventricular fibril￾lation. N Engl J Med. 2002;346:884 – 890. 16. Kudenchuk PJ, Cobb LA, Copass MK, Cummins RO, Doherty AM, Fahrenbruch CE, Hallstrom AP, Murray WA, Olsufka M, Walsh T. Amiodarone for resuscitation after out-of-hospital cardiac arrest due to ventricular fibrillation. N Engl J Med. 1999;341:871– 878. 17. Holmberg M, Holmberg S, Herlitz J. Effect of bystander cardiopulmonary resuscitation in out-of-hospital cardiac arrest patients in Sweden. Resus￾citation. 2000;47:59 –70. 18. Caffrey SL, Willoughby PJ, Pepe PE, Becker LB. Public use of automated external defibrillators. N Engl J Med. 2002;347:1242–1247. IV-4 Circulation December 13, 2005