The United Kingdom’s guidelines on advanced life support for adults were updated in 1997 and endorsed by the European Resuscitation Council in 1998. During 1999 and 2000 the American Heart Association hosted three meetings of international organisations in Dallas to evaluate the evidence on resuscitation. The sets of guidelines that resulted from the international consensus document have a stronger evidence base than their predecessors but have retained their simplicity.

Experts at the Dallas meetings included representatives from the American Heart Association, the European Resuscitation Council, the Heart and Stroke Foundation of Canada, the Australian Resuscitation Council, the New Zealand Resuscitation Council, the Resuscitation Council of Southern Africa, the Latin American Resuscitation Council, and Japan. All aspects of resuscitation were reviewed, and the quality of the evidence supporting each resuscitation intervention was appraised.

The European Resuscitation Council has accepted most of the recommendations from the international consensus document, and its revised guidelines for adults have been summarised in three papers. The Resuscitation Council (UK) has adopted the updated European guidelines in their entirety, and these are incorporated into its latest manual for providers of courses on advanced life support.

Lay people will no longer be trained to check for the carotid pulse to confirm cardiac arrest. Several studies have shown that assessment of the carotid pulse by lay people is time consuming and unreliable: their assessment is wrong in up to 50% of cases. This change in the guidelines is an example of evidence based practice applied to resuscitation. Healthcare professionals will continue to be taught to check the carotid pulse to confirm cardiac arrest. The ratio of chest compressions to ventilations is now 15:2 for both one person and two-person cardiopulmonary resuscitation. A ratio of 15:2 provides more chest compressions per minute than a ratio of 5:1. The external cardiac compression rate remains 100 a minute.

Once the trachea has been intubated, chest compressions, at a rate of 100 a minute, should continue uninterrupted (except for defibrillation or pulse checks when indicated), and ventilation should be continued at roughly 12 breaths a minute. A pause in the chest compressions allows the coronary perfusion pressure to fall substantially. When compressions are resumed there is some delay before the original coronary perfusion pressure is restored. Thus, chest compressions without interruption for ventilation result in a substantially higher mean coronary perfusion pressure.

As an extension of this concept, using only compression in cardiopulmonary resuscitation is now advocated as an option in telephone assisted cardiopulmonary resuscitation. This follows evidence that many lay rescuers are reluctant to perform mouth to mouth ventilation and consequently fail to provide any basic life support. These ideas are still at the research stage, but progress is being made rapidly

A number of changes have been made to the recommendations for drug treatment in advanced life support. An intravenous bolus of amiodarone 300 mg should be considered when the patient has ventricular fibrillation or when pulseless ventricular tachycardia does not respond to three shocks (2300 J, 200 J, 360 J). Atropine 3 mg is now indicated for pulseless electrical activity (electromechanical dissociation) with a ventricular rate of less than 60 a minute, as well as for asystole. The international guidelines recommend a single intravenous dose of 40 units of vasopressin as an alternative to adrenaline in cases of ventricular fibrillation or pulseless ventricular tachycardia refractory to three initial shocks. The European Resuscitation Council and the Resuscitation Council (UK) are awaiting further evidence before adopting this recommendation and will continue to recommend epinephrine (adrenaline) 1 mg every three minutes during cardiopulmonary resuscitation. A recent study of cardiac arrests occurring in hospital failed to detect any advantage for survival of vasopressin over epinephrine. The administration of "high dose” epinephrine (5 mg) and bretylium is no longer recommended.

The advanced life support algorithm, which is relatively simple and universal, remains essentially unchanged. The peri-arrest algorithms of the European Resuscitation Council have been modified, and an algorithm dealing specifically with atrial fibrillation has been added. Difficulty in obtaining the raw material for isoprenaline has driven the recommendation of low dose epinephrine as an alternative treatment for symptomatic bradycardias resistant to atropine. Amiodarone is the preferred drug for treating broad complex tachycardias, although lidocaine (lignocaine) remains an alternative. The narrow complex tachycardia algorithm now includes the recommendation of a synchronised direct current shock if the heart rate exceeds 250 beats a minute and the patient has no pulse. The algorithm for the management of atrial fibrillation is complex. Patients are classed as having high, intermediate, or low risk, and the treatment options depend partly on the duration of the atrial fibrillation. The new guidelines are clearly more evidence based. The challenge is to prove their effectiveness in terms of improved outcome for patients in cardiac arrest.

Ref: European resuscitation council guidelines

On behalf of a team of North Carolina university and Area Health
Education Center librarians, we are pleased to announce the completion
of a new Evidence-Based education web site:

This site provides a collection of resources that support teaching and learning EBM for faculty, librarians, students, and other health care professionals.

Ref: (web)

During the 1980s, surgery for chronic otitis media with effusion (glue ear) increased greatly without obvious reason. An Effective Health Care bulletin on the treatment of persistent glue ear in children was distributed nationally to NHS decision-makers in 1992. Based on systematic review, the bulletin concluded that surgery should be restricted to children with an extended period of substantial hearing impairment, with persistence and severity established by watchful waiting. Surgery rates before and after distribution of the bulletin were evaluated.

Quarterly numbers of D151 procedures – insertion of a ventilation tube through the tympanic membrane – performed in children aged under 15 in England from 1989 to 1996 were obtained from the hospital episodes system. Per capita regional and national rates for this procedure were calculated.

A generalised linear model with a heterogeneous first order autoregressive structure and repeated measures by region was applied. This approach consistently identifies the best autoregressive structure (the model adjusts for the relatedness of sequential observations over time). We investigated regional variations in surgical rates by comparing standard error terms from the model before and after distribution of the bulletin.

Overall, the model included data from 14 regions, each of which provided results from 28 quarters, half before and half after distribution of the bulletin.

In 1992 grommet insertions were conducted at a rate of 2.1 per 1000 children, with regional rates varying by a factor of two. A small increase in the rate during the three years before distribution of the bulletin became a decrease in the four years after publication (-0.044 (-0.080 to –0.011); P<0.0001). The decrease in quarterly rate from 1992 onwards was seen consistently across the regions.

The changing trend in surgery suggests that 89,800 procedures were avoided nationally in the four years after the bulletin, providing a theoretical saving of £27m at 1992-3 prices. Regional variations in the numbers of surgical procedures undertaken were 30% smaller after distribution of the bulletin than before (SE 0.0169 v 0.0242). Our findings were not substantially altered by analysing procedures under the broader code D15 (drainage of the middle ear) or by age range.

Distributing printed recommendations to decision makers may influence surgery rates, since a trend towards a reduction in the number of grommet operations was seen after distribution of the bulletin. Rates for tonsillectomy – another elective procedure in the same specialty – increased steadily over the same period, suggesting that the change was specific to persistent glue ear and thus was related to the bulletin.

The change cannot be attributed to the bulletin alone, which was commissioned because of pre-existing concerns about appropriate use of the procedure. Its publication received coverage in the medical and academic press, possibly encouraging doctors to examine their own practices and bring about behavioural change.