Since cardiopulmonary resuscitation (CPR) was established in the early 60s,¹ the original resuscitation procedure still holds its place. However, many changes, ideas, and issues regarding the original procedure have been discussed and addressed in American Heart Association-sponsored emergency cardiac care (ECC) and CPR conferences held in Dallas, Texas in 1969, 1974, 1979, 1985, and, most recently, in February 1992. Although some amendments regarding ECC and CPR have been made, some are still under review for approval. In the 1992 meeting there were over 500 participants, including more than 130 representatives from foreign countries.

Each conference deals with specific themes concerning ECC and CPR. The theme of the 1992 conference was concerned with the "chain of survival" which summarizes ECC and CPR.² Because the conference is an open forum, any person can present his views to the members of the panel or he can challenge the specific issue in a frank and open dialogue. The panel, consisting of several eminent professionals in their specialty, will later meet to discuss the issues and problems brought up in the conference as well as the American Heart Association (AHA) evaluation forms and questionnaires that have been answered by the participants.

After thorough discussion during the next several months, the new standards and guidelines in ECC and CPR (basic and advanced cardiac life support) would be published. As a result of the 1992 conference, the following areas are expected to have some changes.

To prevent cross infection, the new recommendation is the use of mouth-to-mask ventilation. It is imperative to teach all medical professionals working in the health care delivery system to learn how to use this technique. This is mainly to prevent cross infection of deadly diseases. The public will be given the option to learn this technique as well as to use the face shield or filter. The recommendation will emphasize that all rescuers with lesions, cuts, or sores in or around the mouth or hand who have any doubt that they had direct contact with the victim's blood or blood-contaminated body fluids should wash promptly and contact their physicians³

The AHA will recommend that all medical professionals should enforce the use of gloves as a means of protection, especially when there is a risk of cross infection. Emphasizing the use of gloves will be an integral part of all CPR courses. The AHA will also recommend that re-certification for all providers in CPR should be annually instead of every two years. It is expected that the time for rescue ventilation will be longer than previously applied. The addition of half a second would provide a better ventilation. In return, the ventilation/minute may or may not be changed or affected. The emphasis will be on tidal volume.

In the United States, a nationwide emergency telephone number (911) has been recommended. Since only a few states presently have this service, other states have passed or are pending to implement this "911" service. This will help to enforce the new standard to "phone first" before the initiation of resuscitation.

The AHA will recommend new criteria for stopping CPR.⁴ They are (1) when effective spontaneous circulation and respiration have been restored; (2) when resuscitation efforts have been transferred to another responsible person who will continue basic cardiac life support; (3) when a physician (or someone directed by the physician) assumes responsibility; (4) when the victim is transferred to trained personnel who have been delegated with emergency medical service responsibilities; and (5) when the rescuer is exhausted and unable to continue.

The new standard of basic life support will also include the teaching of the recovery position. This position is safe, easy to apply, and highly recommended, particularly when the first responder is by himself and need to leave the recovered patient alone during activation of the emergency medical services.

Recent studies have shown the effectiveness of early defibrillation, particularly in ventricular fibrillation. The resuscitation outcome is better when the interval between the time of arrest and the time of applying DC shocks is shorter. With the improved success rate of these studies, the AHA has highly recommended the use of the automatic external defibrillator in advanced life support procedures. At the present time, most of the American states and Scotland are using this device in their emergency medical services, i.e., the ambulances are equipped with the machine. All of their emergency medical technicians and paramedics are well acquainted with its applications. Teaching the layperson how to use this machine is highly recommended since it does not take a long time to teach the defibrillation procedures.

The laryngeal mask and combi-tube are excellent devices, easy to use, effective, and need no expertise. However, there are not enough studies to justify their efficacy or to substitute other devices in use. Although the panel of experts recommended that the devices undergo further studies, it did not discourage their use during CPR.

The monitoring of CPR performance using 02 saturation or disposable end-tidal C02 (ETC02) devices has been recommended. These devices are reliable tools and do not interfere with CPR procedure. The disposable ETCO, monitor is a cheap, effective, and excellent device.

Regarding drug utilization, the following drugs are under scrutiny. For sodium bicarbonate, the same rules and regulations would be enforced. The emergency cardiac care committee will continue the existing policy of using sodium bicarbonate with caution and with emphasis on blood gas analysis. There have been a few recent studies using a higher dose of adrenaline (0.2 mg/kg) that showed a positive effect on animals, however, these studies did not have conclusive evidence in humans. Most likely, the AHA will not recommend the use of a high dose of adrenaline in humans but will recommend that additional multi-center studies to be continued. The previous restrictions on the use of calcium chloride still apply.⁵

Concerning the immediate use of tissue plasminogen activator (tPA), most studies show the importance of immediate administration of this drug after myocardial infarction. These studies show that early administration of tPA has a significant improvement in recanalization and improvement in the perfusion of cardiac muscles as well as a reduction in mortality from myocardial infarction, particularly the anterior ones. The new guidelines will most likely approve paramedics to give early administration of tPA, after the normal rhythm is established.

The task force on resuscitation from North America, Europe, and Australia have recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest (Utstein style). ⁶ In the following few months, the new standards/guidelines will be announced by the AHA. These new guidelines are expected to help and further improve the delivery of emergency cardiac care and CPR which will result in a better outcome. It is expected that there will be more emphasis on phone first, recovery position, protection against cross infection, education, reporting long-term evaluation, the early use of defibrillators in and out of hospitals, and less emphasis on the immediate use of drugs except the early administration of tPA.

Chairman, National CPR Committee

Associate Professor and

Consultant Anesthetist

Division of Anesthesia

College of Medicine

P.O. Box 2925

Riyadh 11461, Saudi Arabia

2. Flint LS. Strengthening the chain of survival. Bull Saudi Heart Assoc 1990;2(3):154-64.
2. American Heart Association. Risk of infection during CPR training and rescue: supplemental guidelines.

JAMA 1989;262(19): 2714-5.

4. Willens J. Big changes in the wind. Nursing 1991:53-6.

Journal of the Saudi Heart Association, Vol. 4, No. 3, 1992