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  Planned, practiced response with CPR/AEDs yields survival rates of 49-74%

What Have We Learned About CPR? 330,000 die annually from coronary heart disease CDC 60% from Sudden cardiac 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 Even pros don’t do good CPR! Too slow Too shallow No CPR x 24-49% of the arrest!

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

Most significant changes (cont.) 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? 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? 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? 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” (O2, ATP depletion)

Chest Compressions 2005 (New):  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 2000 (Old):  Less emphasis was given to need for adequate depth, complete chest recoil, and minimizing interruptions

Chest Compressions cont’d Why:  If chest not allowed to recoil: 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 Why:  Study of CPR performed by healthcare providers found that: ½ of chest compressions too shallow No compressions provided during 24% to 49% of CPR time

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

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

Rescue Breathing without Compressions cont’d Why:  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 2005 (New):  Each rescue breath should be given over 1 second and produce visible chest rise  Avoid breaths that are too large or too forceful  Manikins configured so that visible chest rise occurs at ml 2000 (Old):  Rescue breaths over 1-2 seconds  Recommended tidal volume for adult rescue breaths was 700ml-1000ml

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

Rescue Breaths with Compressions cont’d Why:  Ventilation-Perfusion Ratio The best oxygenation of blood and elimination of CO2 occur when ventilation (volume of breaths x rate) closely matches perfusion During CPR, blood flow to lungs is about 25-33% of normal Less ventilations needed during cardiac arrest than when patient has perfusing rhythm

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

2 Rescuer CPR with Advanced Airway 2005 (New):  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 2000 (Old):  Recommended “asynchronous” compressions and ventilations  Ventilation rate of per minute  Rescuers taught to re-check for signs of circulation “every few minutes”

2 Rescuer CPR with Advanced Airway cont’d Why:  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 2005 (New):  In patients with suspected cervical spine injuries-if unable to open airway using the jaw thrust, use the head-tilt chin lift 2000 (Old):  Jaw thrust without head tilt taught to both lay rescuers and healthcare providers

Airway/Trauma Victims cont’d Why:  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 2005 (New): BLS healthcare provider checks for:  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 2000 (Old):  Healthcare provider checked for adequate breathing for victims of all ages Why:  Children may demonstrate breathing patterns (rapid, grunting) which are adequate but not normal  Assessment for adequate breathing is more consistent with advanced provider skill

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

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

Lone Healthcare Provider-”phone first” vs. “CPR first” 2005 (New):  Tailor sequence to most likely cause of cardiac arrest “Phone First” Sudden witnessed collapse (adult or child)-likely to be cardiac in origin. Call 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 and get the AED

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

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

“Child” BLS cont’d Why:  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 2005 (New):  Chest compressions indicated if HR <60 and signs of poor perfusion, despite adequate ventilation 2000 (Old):  Same recommendation in 2000 guidelines but it was not incorporated into the BLS training

Symptomatic Bradycardia Infants/Children cont’d Why:  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 2005 (New):  Use heel of 1 or 2 hands 2000 (Old):  Use heel of 1 hand Why:  Child manikin study showed that rescuers performed better chest compressions using the “adult” technique

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

Compression to Ventilation Ratios Infants/Children 2005 (New):  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):  15:2 adults 5:1 infants/children

Compression to Ventilation Ratios Infants/Children cont’d Why:  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 2005 (New):  Airway obstructions classified as mild or severe  Rescuers should act only if signs of severe obstruction present poor air exchange Increased respiratory distress Silent cough Cyanosis Inability to speak or breath

Foreign Body Airway Obstruction cont’d 2005 (New) cont’d  If victim becomes unresponsive ACTIVATE and begin CPR When airway opened during CPR, look in mouth and remove object if seen No blind finger sweeps

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

Foreign Body Airway Obstruction cont’d Why:  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 2005 (New):  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 2000 (Old):  3 stacked shocks recommended Why:  3 shocks were based on use of monophasic waveforms  New biphasic defibrillators have a higher first- shock 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 2005 (New):  Initial and subsequent shocks for VF/pulseless VT in adults 360J 2000 (Old):  200, J, 360J Why:  One dose to simplify training

Biphasic Defibrillation Dose 2005 (New):  Initial shock for adults: J for biphasic truncated exponential waveform  120J for rectilinear biphasic waveform  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 200J

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

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

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

Community/Lay Rescuer AED Programs cont’d 2005 (Why):  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

Tx of Arrhythmias AHA 2005 Guidelines

CPR Algorithm

Pulseless Algorithm

Brady- Arryhthmias

Tachy- Arryhthymias

Pulseless Arrest 4 Basic Rhythms Shockable V-fib V-Tach Non-Shockable Asystole PEA

Shockable Rhthyms Ventricular Tachycardia V-Fib  Shock early  ABC’s Tx of VT/VF  Shock- biphashic 200j, monophasic 360j (one x)  CPR-IV, ETT  Shock  CPR-epi/vasopressin  Shock  CPR-Lido/amiodarone  Shock  CPR-epi  Shock  CPR- lido/amio

NON-Shockable PEA Asystole Tx of Asystole & PEA  CPR-IV,airway  Meds-vasopressin/epi  CPR-2 min  Meds-epi,atropine*  CPR  Meds-epi,atro  CPR  *Atropine used in PEA, only for HR < 60

Contributing Factors H’s and T’s Hypovolemia Hypoxia Hydrogen ion (acidosis) Hypo/hyperkalemia Hypoglycemia Hypothermia Toxins (drugs) Tamponade (cardiac) Tension PTX Thrombosis (coronary or pulmonary) Trauma

Tachycardia’s Stable vs. Unstable Stable  MI  12 lead  Narrow complex  Wide complex  Treat causes H’s and T’s Unstable  Altered MS  CP  Hypotension  Signs of shock

Tx of Stable Tachycardias A-fib/flutter  Vagal maneuvers  Diltiazem (Ca++ channel blocker) SVT  Adenosine V-Tach (WITH PULSE)  Antiarrhythmic: Lido, Amio, (Mg+ for torsades)

Tx of Unstable Tachycardias Perform immediate synchronized cardioversion  MI  Sedate if conscious  DO NOT DELAY CARDIOVERSION

Bradycardias Tx of Bradycardias Stable  MI  Adequate perfusion?  Monitor BP!! Unstable  Poor perfusion  Immediate transcutaneous pacing  Consider atropine while awaiting pacer  Consider epi or dopamine if pacing ineffective

ACLS Class Recommendations Class I – Always do this! Class IIa – Intervention of choice. Class IIb – Give careful consideration. Class Indeterminate – Clinical judgment Class III – Not recommended!