AHA Guidelines History

The Things We Take For Granted: A Detailed History of the American Heart Association Guidelines.

When the population thinks of cardiopulmonary resuscitation (CPR), it is a given it exists, much in the same way a light bulb or massive supermarkets exists.  That is to say — it is something which is known to exist, and so commonly ingrained in the psyche of American mentality where many times, it is simply thought of as a given — a lifesaving mechanism society enjoys through the convenience of it having being invented.  However, there are two very important topics regarding CPR and related emergency cardiac care (ECC) which, although they are many times lost in translation, are very important to understand and become familiar with.  These are the subjects of the very history of CPR as well as the current guidelines, known as the American Heart Association Guidelines for CPR and ECC and how they came to be, how they are modified, and what the most current Guidelines have to teach society with regards to this life-saving field.

To begin with, in order to understand something of such an important role in the critical care infrastructure of today, it is vitally important to understand the founding history of the same.  It may be hard to fathom, but the historical roots of CPR and emergency cardiac care extend back further in history than the United States of America has existed. It was roughly about 35 to 36 years before the Declaration of Independence that the “Paris Academy of Science recommended the use of mouth-to-mouth resuscitation for drowning victims.”[1]   The idea of the ability to bring a clinically dead victim “back to life” had indeed been formulated.  It is very important to keep in mind this was a period of history during which the world was engulfed in revolution, from the French Revolution to the American Revolution, as well as new revolutions in scientific and medical discovery.  This was The Age of Enlightenment.  How fitting is it, then, where such a technique has been refined over the past 270+ years, and was radically different from the medical procedures of the former era, came to be during this time?  This was the age of the discovery of inoculation, true anatomy, and autopsies.  Truly, with these major advances, including the discovery of the efficacy of mouth-to-mouth resuscitation, the tides of medical discovery and protocol were markedly turning away from the pseudoscience and mythology of alchemy in favor of sound, evidence-based scientific discovery and reasoning.  As time went on, as with all new concepts, more advancements were made, and the science behind resuscitation advanced, leading up to the first use of chest compressions in the late 19th century.  Again, most of society subscribes to the belief where it is very important to understand at least a basic history of this topic.  A great model to aid in the comprehension of these advancements can be seen in the following timeline, as published by the American Heart Association:

History of Cardiopulmonary Resuscitation and Timeline

1740:   The Paris Academy of Sciences officially recommended mouth-to-mouth resuscitation for drowning victims.
1767:   The Society for the Recovery of Drowned Persons became the first organized effort to deal with sudden and unexpected death.
1891:   Dr. Friedrich Maass performed the first equivocally documented chest compression in humans.
1903:   Dr. George Crile reported the first successful use of external chest compressions in human resuscitation.
1904:   The first American case of closed-chest cardiac massage was performed by Dr. George Crile.
1954:   James Elam was the first to prove that expired air was sufficient to maintain adequate oxygenation.
1956:   Peter Safar and James Elam invented [modern] mouth-to-mouth resuscitation.
1957:   The United States military adopted the mouth-to-mouth resuscitation method to revive unresponsive victims.
1960:   Cardiopulmonary resuscitation (CPR) was developed. The American Heart Association started a program to acquaint physicians with close-chest cardiac resuscitation and became the forerunner of CPR training for the general public.
1963:   Cardiologist Leonard Scherlis started the American Heart Association’s CPR Committee, and the same year, the American Heart Association formally endorsed CPR.
1966:   The National Research Council of the National Academy of Sciences convened an ad hoc conference on cardiopulmonary resuscitation.  The conference was the direct result of requests from the American National Red Cross and other agencies to establish standardized training and performance standards for CPR.
1972:   Leonard Cobb held the world’s first mass citizen training in CPR in Seattle, Washington called Medic 2.  He helped train over 100,000 people the first two years of the programs.
1973:  Second National Conference on CPR and ECC.
1979:  Advanced Cardiovascular Life Support (ACLS) is developed after discussions held at the Third National Conference on CPR.
1981:  A program to provide telephone instructions in CPR began in King County, Washington.  The program used emergency dispatchers to give instant directions while the fire department and EMT personnel were en route to the scene.  Dispatcher-assisted CPR is now standard care for dispatcher centers throughout the United States.
1983:  AHA convened a national conference on pediatric resuscitation to develop CPR and ECC Guidelines for pediatric and neonatal patients.
1985:  Fourth National Conference on CPR and ECC.
1988:  AHA introduces first pediatric courses, pediatric BLS, pediatric ALS and neonatal resuscitation, cosponsored by The American Academy of Pediatrics (AAP).
1990:  Early Public Access Defibrillation (PAD) programs are developed with the goal in mind to provide training and resources to the public so they are able to aid in the successful. resuscitation of sudden cardiac arrest victims.
1992:  Fifth National Conference on CPR and ECC.
1992:  International Liaison Committee on Resuscitation (ILCOR) founded.
1999:  First task force on first aid was appointed. First International Conference on Guidelines for CPR and ECC.
2004:  AHA and ILCOR releases a statement regarding the use of AEDs on children. It is determined that an AED may be used for children 1 to 8 years of age who have no signs of circulation.
2005:  AHA developed the Family & Friends® CPR Anytime® kit, a revolutionary product that allows anyone to learn the core skills of CPR in just 20 minutes. The kit contains everything needed to learn basic CPR, AED skills and choking relief anywhere, from the comfort of your home to a large group setting.
2005:  The 2005 International Consensus on ECC and CPR Science with Treatment Recommendations (CoSTR) Conference produces the 2005 American Heart Association Guidelines for CPR & ECC. These Guidelines reveal a new compression:ventilation ratio as well as changes to AED usage.
2008:  The AHA releases a statement about Hands-Only™ CPR, saying that bystanders who witness the sudden collapse of an adult should dial 911 and provide high-quality chest compressions by pushing hard and fast in the middle of the victim’s chest.
2010:  The 2010 International Consensus on ECC and CPR Science with Treatment Recommendations (CoSTR) Conference produces the 2010 American Heart Association Guidelines for CPR & ECC; 50th Anniversary of CPR. [2]

The American Heart Association’s Guidelines for CPR and ECC

Consequently, the rich history detailed in this timeline of discovery and advance in CPR techniques could not have been possible without the scientific and medical catalyst of today’s Guidelines.  This catalyst, of course, is the formation of the American Heart Association’s CPR Committee in 1963, followed by formal endorsement of CPR by the AHA the same year.  Since that time, committees have guided formal recommendations for both healthcare professional and bystander-assisted cardiac care in instances requiring CPR or ECC.  These recommendations only come to fruition after careful consideration of a new trend, based soundly on scientific data and the results of monitored research studies.  For instance, the creation of advanced cardiac life support (ALCS) in 1979 was a major breakthrough for the streamlining of critical cardiac care protocols nationwide, and this protocol still exists as the gold standard for how hospital staff address patients who develop sudden cardiac arrest in hospital settings.  This protocol was developed, as mentioned above, at the Third National Conference on CPR.  As time passed, the need for more standardized procedures for dealing with sudden cardiac emergencies, coupled with advances in technology which allowed for greater AED access to bystander responders led to the creation of the 2005 AHA Guidelines for CPR and ECC.

The Guidelines created a standard protocol for dealing with these events which were able to be disseminated and adopted by healthcare facilities and emergency responders nationwide.  At the creation of the Guidelines, it was decided, in order to perfect the protocol, they would be reviewed and amended every 5 years, as advances in technology as well as clinical trials uncovered more effective practices and recommendations which had the potential to, in turn, save more lives.  Now, at the time of the 2005 Guidelines, bystander mouth-to-mouth was still in practice as standard protocol for dispatcher-led, citizen-assisted resuscitation.  However, between the effective date of these guidelines, but 2 years before the next scheduled set of modification, a clinical trial had suggested the efficacy of mouth-to-mouth CPR with chest compressions was no more effective than compression only (of Hands-Only©) CPR in patients assisted by untrained bystanders.  This study, coupled with the fact that many bystanders are hesitant to perform mouth-to-mouth resuscitation, led to one of the most radical changes to standard CPR recommendations by doing away with the mouth-to-mouth protocol for untrained bystander-assisted cases in favor of compression-only guidelines.  The data in support of this recommendation had a profound impact on the possibility of saving lives, so the AHA released a special 2008 bulletin regarding this change.  This change was formally reflected in the 2010 Guidelines.

Inasmuch, it is very important to keep in mind the Guidelines can be interpreted as overly technical for the bystander-responder.  For instance, one of the recommendations from 2005 to 2010 involved revisions to the use of the drug atropine and when it should be administered.  However, since the majority of the bystanders in the community do not have a vial of atropine on their person, suggestions such as these obviously do not apply to bystander-assisted CPR recommendations.  Therefore, in order to avoid confusion and simplify bystander response, the AHA has consistently published a side-by-side comparison of the changes from each new set of guidelines to the next, as well as a more polished, official update publication that is most useful for first responders and hospital staff.[3]  The current Guidelines, the 2015 revision, introduced some very new concepts from the beginning, but as far as changes related to bystander-led assistance, the changes are subtle.  However, some of the main changes include increasing the recommended number of compressions per minute to 100-120 as opposed to the 2010 recommendation of a maximum of 100 per minute.  Furthermore, an added emphasis on the above-mentioned chest-only compression recommendations for untrained bystanders aims to streamline increased survival rates by lessening the confusion that is so easily experienced when an untrained bystander happens upon a patient suffering from a sudden cardiac event, including cardiac arrest, which requires resuscitation.  Additionally, a good example of a research-led addition to the Guidelines can be evidenced by the new recommendation of bystander-assisted naloxone injection for patients in distress with a known or suspected history of opioid dependence and/or previous overdose.  This comes as the FDA approved widespread layperson access to this life-saving emergency injection which can reverse the effects of an opioid overdose, where CPR would likely be only minimally beneficial.  Finally, another major emphasis in bystander-led assistance recommendations is that of the correct identification of agonal breathing as opposed to other abnormal respiration patterns.  This change focuses on the instructions given to the bystander responder by 911 emergency dispatchers, as correct identification and instruction of this often wrongly interpreted event has the possibility of increasing the chance of survival exponentially.

Conclusion

Therefore, by understanding the history of how CPR came to be and augmenting that knowledge with the current recommendations set forth by the American Heart Association, the informed bystander emerges into society with a better probability of success when helping the potential victim of sudden cardiac arrest.  While it would be ideal for no person to ever have to experience this event without a trained medical professional present or nearby, this is not an ideal world.  The committees and conferences which have served to improve and evolve the standard of emergency cardiac care recognized this fact and continue to serve as the guiding force for how society handles these unfortunate emergency events.  As technology advances, and life-saving AED devices become more readily available to the layperson, to the neighbor, and to everyday consumers and shoppers, it is likely that each iteration of the Guidelines will have more detailed recommendations for bystander-assisted defibrillation to augment the scientifically proven efficacy of the current standard.  These future recommendations can then be used as an evidence-based advocacy for the proliferation of community-based training programs for layperson deployment of such devices.  Certainly, the current era is a very exciting time to be alive, for both the bystander-responder as well as the clinically dead patient, who more than likely owe their resuscitation to the AHA Guidelines.  So, with all of this in mind, these advances in technology beg the following questions:  With such progress and rapidly-improving techniques, will history remember this time as a second “Age of Enlightenment”, much as the 18th century was in its day?

References

American Heart Association (2015).  Guideline Updates for CPR and ECC.  Retrieved from             https://eccguidelines.heart.org/wp-content/uploads/2015/10/2015-AHA-Guidelines-           Highlights-English.pdf.

American Heart Association (2015).  American Heart Association (2015).  History of CPR.          Retrieved from    http://cpr.heart.org/AHAECC/CPRAndECC/AboutCPRFirstAid/HistoryofCPR/UCM_47            5751_History-of-CPR.jsp

Footnote1:

[1]   American Heart Association (2015).  History of CPR.  Retrieved from http://cpr.heart.org/AHAECC/CPRAndECC/AboutCPRFirstAid/HistoryofCPR/UCM_475751_History-of-CPR.jsp

Footnote2:

[2] American Heart Association (2015).  History of CPR.  Retrieved from http://cpr.heart.org/AHAECC/CPRAndECC/AboutCPRFirstAid/HistoryofCPR/UCM_475751_History-of-CPR.jsp

Footnote3:

[3] The comparison chart for 2005 to 2010 can be found at http://www.heart.org/idc/groups/heart-public/@wcm/@ecc/documents/downloadable/ucm_317267.pdf. | The 2010 to 2015 comparison can be found at http://www.sca-aware.org/sites/default/files/comparison_chart_2015_aha_guidelines_for_cpr_and_ecc.pdf.  The official published changes and updates to the Guidelines can be found at American Heart Association (2015).  https://eccguidelines.heart.org/wp-content/uploads/2015/10/2015-AHA-Guidelines-Highlights-English.pdf.

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