2005 AHA Guideline Changes BLS for Healthcare Providers

2005 AHA Guideline Changes BLS for Healthcare Providers ACLS Updates

Purpose of BLS Changes To improve survival from cardiac arrest by increasing the number of victims of cardiac arrest who receive early, high-quality CPR q Planned, practiced response with CPR/AEDs yields survival rates of 49 -74%

What Have We Learned About CPR? n n n 330, 000 die annually from coronary heart disease CDC 60% from Sudden cardiac event @ home or en route 85 -90% in VF/VT arrest 2 -3 x greater survival if CPR is immediate, with defib <5 min. EMS relies on trained, willing, equipped public

Less than 1/3 get bystander CPR or don’t do good CPR! n n n Too slow Too shallow No CPR x 24 -49% of the arrest!

Most significant changes 2005 IT’S ALL ABOUT BLOOD FLOW! n Emphasis on effective CPR q n Fast; deep; 50/50; minimal interruption Single compression-to-ventilation ratio q 30: 2 single rescuer adult, child, infant, excluding newborns

Most significant changes (cont. ) n n n Each shock from an AED should be followed by 2 minutes of CPR (5 cycles of 30: 2) starting with compressions Each rescue breath should take one second and produce visible chest rise Reaffirmation that AEDs should be used for kids 1 -8 y. o.

Why change compressions? n n n When compressions stop, blood flow stops! Universal compression ratio easier to learn/retain Higher ratio yields more blood flow; keeps pump “primed”

Why shorten breaths? n n Large volume breaths increase ITP; decrease venous return to heart Long breaths interrupt compressions Hyperventilation decreases coronary and cerebral perfusion pressures Over-ventilation increases air in stomach; regurgitation/aspiration

Why from 3 shocks to 1? n n Biphasic defibrillators eliminate VF 85% on first shock Current AED sequence can delay CPR 37 seconds Long CPR interruptions decrease likelihood of subsequent successful shocks Myocardial “stunning” (O 2, ATP depletion)

Chest Compressions n 2005 (New): q q q Push hard, fast, rate of 100 per minute Allow full chest recoil after each compression Minimize interruptions (no more than 10 seconds at a time) except for specific interventions (advanced airway/AED)

Chest Compressions cont’d n 2000 (Old): q Less emphasis was given to need for adequate depth, complete chest recoil, and minimizing interruptions

Chest Compressions cont’d n Why: q If chest not allowed to recoil: n n n q less venous return to heart reduced filling of heart Decreased cardiac output for subsequent chest compressions When chest compressions are interrupted, blood flow stops and coronary artery perfusion pressure falls

Chest Compressions cont’d n Why: q Study of CPR performed by healthcare providers found that: n ½ of chest compressions too shallow n No compressions provided during 24% to 49% of CPR time

Changing Compressors Every 2 Minutes n 2005 (New): q n 2000 (Old): q n If more than 1 rescuer present, change “compressor” roles every 2 minutes Rescuers changed when fatigued-usually did not report feeling fatigued until 5 min. or more Why: q In manikin studies, rescuer fatigue developed in as little as 1 -2 minutes(as demonstrated by inadequate chest compressions)

Rescue Breathing without Compressions n 2005 (New): q q n 10 -12 breaths per minute (adults) 1 every 5 -6 seconds 12 -20 breaths per minute for infant or child 1 every 3 -5 seconds 2000 (Old): q q 10 -12 breaths for adults 20 breaths for infant or child

Rescue Breathing without Compressions cont’d n Why: q Wider range of acceptable breaths for infant and child will allow the provider to tailor support to patient Note: If you are assisting lay rescuer-they are not taught to deliver rescue breaths without chest compression

Rescue Breaths with Compressions n n 2005 (New): q Each rescue breath should be given over 1 second and produce visible chest rise q Avoid breaths that are too large or too forceful q Manikins configured so that visible chest rise occurs at 500 -600 ml 2000 (Old): q Rescue breaths over 1 -2 seconds q Recommended tidal volume for adult rescue breaths was 700 ml-1000 ml

Rescue Breaths with Compressions n Why: q Oxygen Delivery n Oxygen delivery is product of oxygen content in the arterial blood and cardiac output (blood flow) n During first minutes of CPR for VF , initial oxygen content in blood adequate/ cardiac output is reduced n Effective chest compressions more important than rescue breaths immediately after VF

Rescue Breaths with Compressions n Why: q Ventilation-Perfusion Ratio n The best oxygenation of blood and elimination of CO 2 occur when ventilation (volume of breaths x rate) closely matches perfusion n During CPR , blood flow to lungs is about 2533% of normal n Less ventilations needed during cardiac arrest than when patient has perfusing rhythm

Rescue Breaths with Compressions n Why: q Hyperventilation leads to: n Increased positive pressure in the chest n Decreased venous return to the heart n Limited refilling of heart n Decreased cardiac output during subsequent compressions n Gastric distention/vomiting

2 Rescuer CPR with Advanced Airway n 2005 (New): q q No pause for ventilation when there is an advanced airway in place 8 -10 breaths per minute

2 Rescuer CPR with Advanced Airway cont’d n 2000 (Old): q q q Recommended “asynchronous” compressions and ventilations Ventilation rate of 12 -15 per minute Rescuers taught to re-check for signs of circulation “every few minutes”

2 Rescuer CPR with Advanced Airway cont’d n Why: q q q Ventilations can be delivered during compressions Avoid excessive number of breaths During CPR, blood flow to lungs decreased, so lower than normal respiratory rate will maintain adequate oxygenation

Airway/Trauma Victims n 2005 (New): q n In patients with suspected cervical spine injuries-if unable to open airway using the jaw thrust, use the head-tilt chin lift 2000 (Old): q Jaw thrust without head tilt taught to both lay rescuers and healthcare providers

Airway/Trauma Victims n Why: q Jaw thrust difficult maneuver to learn, may not effectively open airway and it can cause spinal movement Opening the airway is a priority in an unresponsive trauma victim Manual stabilization preferred over immobilization devices during CPR

“Adequate” vs. Presence or Absence of Breathing n 2005 (New): n BLS healthcare provider checks for: q q n adequate breathing in adult victims presence or absence of breathing in children and infants Advanced healthcare provider (with ACLS and PALS/PEPP) will assess for adequate breathing in victims of all ages

Adequate vs. Presence or Absence of Breathing cont’d n n 2000 (Old): q Healthcare provider checked for adequate breathing for victims of all ages Why: q Children may demonstrate breathing patterns (rapid, grunting) which are adequate but normal q Assessment for adequate breathing is more consistent with advanced provider skill

Infant/Child: Give 2 Effective Breaths n 2005 (New): q n Attempt “a couple of times” to deliver 2 effective breaths (that cause visible chest rise) 2000 (Old): q Healthcare providers were taught to move head through a variety of positions to obtain optimal airway opening

Infant/Child: Give 2 Effective Breaths n Why: q q Most common mechanism of cardiac arrest in infants and children is asphyxial Rescuer must be able to provide effective breaths

n Lone Healthcare Provider”phone first” vs. “CPR first” 2005 (New): q Tailor sequence to most likely cause of cardiac arrest n n “Phone First” Sudden witnessed collapse (adult or child)-likely to be cardiac in origin. Call 9 -1 -1 and get the AED “CPR First” Hypoxic Arrest (adult or child)- give 5 cycles or about 2 minutes of CPR before leaving victim to call 9 -1 -1 and get the AED

Lone Healthcare Provider n n 2000 (Old): Tailoring response to likely cause of arrest was not emphasized in training Why: q q Sudden collapse-likely cardiac and early CPR and defibrillation needed Victims of hypoxic arrest need immediate CPR

“Child” BLS Guidelines n n 2005 (New): q Child CPR guidelines for healthcare providers apply to victims from 1 year of age to onset puberty (about 12 -14 years old) 2000 (Old): q Child CPR age 1 -8

“Child” BLS n Why: q q No single anatomic or physiologic characteristic that distinguishes a “child” victim from an “adult” victim No scientific evidence that identifies a precise age to begin adult techniques

Symptomatic Bradycardia Infants/Children n 2005 (New): q n Chest compressions indicated if HR <60 and signs of poor perfusion, despite adequate ventilation 2000 (Old): q Same recommendation in 2000 guidelines but it was not incorporated into the BLS training

Symptomatic Bradycardia Infants/Children cont’d n Why: q Bradycardia is common terminal rhythm in infants and children Do not want to wait for development of pulseless arrest to begin chest compressions if there are signs of poor perfusion and no improvement with 02 and ventilatory support

Child Chest Compressions n 2005 (New): q n 2000 (Old): q n Use heel of 1 or 2 hands Use heel of 1 hand Why: q Child manikin study showed that rescuers performed better chest compressions using the “adult” technique

Infant Chest Compressions n 2005 (New): q n 2000 (Old): q n Use the 2 thumb-encircling technique-sternum compressed with thumbs and use fingers to squeeze thorax Use of fingers to compress chest wall was not described Why: q This technique results in higher coronary artery perfusion pressure

Compression to Ventilation Ratios Infants/Children n 2005 (New): q q n Lone rescuer: Compression to ventilation ratio 30: 2 for infants, children and adults for 2 Rescuer CPR: 15: 2 ratio for infants and children 2000 (Old): q 15: 2 adults 5: 1 infants/children

Compression to Ventilation Ratios Infants/Children n Why: q q q Simplify training Reduce interruptions in chest compressions 15: 2 ratio for 2 rescuer CPR for infants/children will provide additional ventilations

Foreign Body Airway Obstruction n 2005 (New): q q Airway obstructions classified as mild or severe Rescuers should act only if signs of severe obstruction present n n n poor air exchange Increased respiratory distress Silent cough Cyanosis Inability to speak or breath

Foreign Body Airway Obstruction n 2005 (New) q If victim becomes unresponsive n ACTIVATE 9 -1 -1 and begin CPR n When airway opened during CPR, look in mouth and remove object if seen n No blind finger sweeps

Foreign Body Airway Obstruction cont’d n 2000 (Old): q Rescuers taught to recognize n n n q Rescuers taught to ask 2 questions n n q Partial obstruction with good air exchange Partial obstruction with poor air exchange Complete airway obstruction Are you choking? Can you speak? Sequence for unresponsive choking victim was a complicated sequence/included abdominal thrusts

Foreign Body Airway Obstruction n Why: q q q Simplification Compressions during CPR may increase intrathoracic pressure more than abdominal thrusts Blind finger sweeps may injure victims mouth/throat or rescuers finger

Shock /Immediate CPR n 2005 (New): q q Delivery of single shock for VF and pulseless VT followed by immediate CPR Perform 2 minutes of CPR before checking for signs of circulation

Shock /Immediate CPR cont’d n 2000 (Old): q n 3 stacked shocks recommended Why: q q q 3 shocks were based on use of monophasic waveforms New biphasic defibrillators have a higher firstshock success rate 3 -shock sequence can result in delays up to 37 seconds or longer from delivery of shock and delivery of first post-shock compression

Monophasic Defibrillation dose n 2005 (New): q n 2000 (Old): q n Initial and subsequent shocks for VF/pulseless VT in adults 360 J 200, 200 -300 J, 360 J Why: q One dose to simplify training

Biphasic Defibrillation Dose n 2005 (New): Initial shock for adults: 150 -200 J for biphasic truncated exponential waveform q 120 J for rectilinear biphasic waveform q The second dose should be the same or higher Rescuers should use the device-specific defibrillation dose. If rescuer unfamiliar with device-specific dose-use default dose of 200 J q

Biphasic Defibrillation Dose cont’d n 2000 (Old): q n 200 J, 200 -300 J, 360 J Why: q q Simplify defibrillation Support use of device-specific doses

Use of AED’s in Children n 2005 (New): q n 2000 (Old): q n Recommended use of AED’s in children 1 -8 years old Insufficient evidence to recommend for or against use of AED’s in children under 8 years old Why: q Evidence published since 2000 shows AED’s safe and effective for use in infants and children

Community/Lay Rescuer AED Programs n 2005 (New): q q n CPR/AED use by public safety first responders recommended to increase survival rates Insufficient evidence to recommend for or against AED’s in homes 2000 (Old): q Key elements of an AED program included: n n Physician oversight Training of rescuers Integration with EMS Process of CQI

Community/Lay Rescuer AED Programs cont’d n 2005 (Why): q The North American PAD trial reinforced the importance of planned and practiced response. Even at sites with AED’s in place- the AED’s were deployed for less than half the of the cardiac arrests at those sites indicating the need for frequent CPR