The New Guidelines Are Here! The New Guidelines Are Here!


Channeling my inner Steve Martin I’m excited to report that the new American Heart Association (AHA) guidelines for CPR and Emergency Cardiovascular Care have been released.

You can download the entire document as published in Circulation, the official Journal of the AHA here. It’s a long document and you will be able to order your dead tree version from the AHA on November 3.  As always I recommend you buy your books from my good friend Lou Jordan at

The change making the biggest splash in the lay media is moving from Airway, Breathing, Circulation, to Circulation, Airway, Breathing. CAB has been used in some European EMS systems for several years, but the AHA decided that the matter needed more study and so did not make this change in 2005.

Briefly, for trained rescuers, not lay people, the sequence is determine if the person appears to be not breathing (no more pulse check), start rapid and fast chest compressions, then attend to the airway and breathing. As with the 2005 changes, the AHA still emphasizes early defibrillation whenever possible.

For the lay rescuer, the emphasis is on compression only CPR.

Therapeutic Hypothermia is now recommended for patients who have Return of Spontaneous Circulation (ROSC).

Atropine is out for Asystole or Pulseless Electrical Activity (PEA). It is however, still recommended for symptomatic bradycardia.

Amiodarone is recommended as the first line anti arrhythmic for VF/VT, but Lidocaine is acceptable if Amiodarone isn’t available. Lidocaine is also recommended for post ROSC administration in patients who were shocked out of VF/VT.

Adenosine is recommended as a safe and potentially effective therapy in the initial management of stable undifferentiated regular monomorphic wide-complex tachycardia.

The precordial thump is back, for some situations. Someday I’ll have to tell you all the story of how I invented the post cordial thump.

There is a joint AHA/American Red Cross first aid section.

A couple of cautionary notes. First, don’t change what you do  until your system protocols change. Second, this post is based on a quick read of the Executive Summary and a couple of sections of the rest of the guidelines.

The entire document is 300+ pages long, so there is a lot of material to go through. There are significant changes to cardiac arrest and STEMI/ACS treatment, as well as others. It will take time for the changes to get out to every EMS system and for treatment protocols to be changed. Not to mention training both ALS and BLS providers to the new standards.

It is likely to be sometime next spring before all of the changes and new standards are in place and systems have trained all of their personnel.

I’m sure other EMS bloggers will be posting about the changes in the coming days and weeks and I look forward to some lively discussions.  Expect Rouge Medic to have 3,000+ pages of commentary on the 300+ pages of the new guidelines. He wouldn’t be Rogue Medic if  he didn’t!

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After a long career as a field EMS provider, I'm now doing all that back office stuff I used to laugh at. Life is full of ironies, isn't it? I still live in the Northeast corner of the United States, although I hope to change that to another part of the country more in tune with my values and beliefs. I still write about EMS, but I'm adding more and more non EMS subject matter. Thanks for visiting.


  1. When I took my ACLS refresher a few months ago, there were rumors of epinephrine being kicked out of the algorithms…

    Seriously, why am I always taking these classes RIGHT before changes occur?

  2. It always works out that way Minimedic, because standards in medicine always seem to be changing. Not one thing that I learned about CPR when I was first trained is still valid. Not the hand position, number and timing of breaths, rate and number of compressions, or even when and how to use two person CPR. Very little of the ACLS that I learned is still considered valid. Which is good because as science progresses were learn (hopefully) better techniques for treating people.

  3. You weren’t practicing when “artificial respirations” resembled pulling and pushing the patient into the “cobra” yoga position, were you? ‘Cause I literally LOL’d when I heard that…and then realized how far we’ve come in the space of 30-40 years medically.

    • “Back Pressure – Arm Lift” was still shown in first aid books up until the late 1970s, even though it wasn’t actually being used any longer. It was developed in the early part of the 20th century, but nothing came along to replace it until what we call CPR was developed in the late 1950s. When external chest compression was first developed, it was considered a skill that only doctors should perform. The earliest training films to show CPR were released in 1961 or ’62.

      The very first civilian paramedics didn’t come along until the late 1960s, in Miami, FL, not California as most think. Of course, there will always be debate about that. 🙂

  4. I learned in the mid-70’s and when I just found out how compression ratio to breaths has changed PLUS how FAST compressions are done- I don’t buy it!! How in hell is the heart supposed to fill up when someone is compressing it so fast? I just don’t see how the blood can circulate at these quick compressions?

    • Because the heart doesn’t fill nearly as much with compressions as it does with the normal beating of the heart. The rate makes up for the decreased stroke volume. Remember Cardiac Output (CO) = Stroke Volume (SV) x Heart Rate (HR).

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