New York State Protocols Update 2006 Including AHA changes

American Heart Association Approximately 330,000 prehospital and Emergency Department deaths/year in US are from cardiac arrest Survival is 6.4% or less Changes in AHA guidelines are based on research

Major Changes for Everyone Emphasis on effective chest compressions Universal compression:ventilation ratio for lone rescuer 1 Second breaths during CPR 1 Shock, then immediate CPR

Effective Chest Compressions Change: Push hard and push fast Why: Need adequate rate and depth in order to produce blood flow and perfuse vital organs Change: Equal compression/relaxation times Why: Need full recoil of chest in order to have better blood flow Change - not emphasized

Effective Chest Compressions, continued Change: Limit Interruptions to chest compressions Why: Blood flow stops when CPR is interrupted, more compressions in a row provides better blood flow Change –never limited

Universal Compression:Ventilation Ratio Change: 30:2 for lone rescuer, infants through adults (not newborns) Why: Simplify information, longer series of uninterrupted compressions Changed from - 15:2

1 Second Breaths Change: Give the recommended number of breaths, with each breath given over 1 second Why: Lungs require less oxygen during CPR due to decreased blood flow and it is important to reduce interruptions to compressions Changed from - breaths over 1-2 seconds, the more the better

1 Second Breaths, continued Change: Avoid delivering too many breaths or breaths that are too large or too forceful Why: Too much volume in the chest cavity decreases blood return to the heart. Too forceful a breath can cause gastric distention and all it implies. Changed from - belief that more oxygen was better

1 Shock, Immediate CPR Change: Deliver 1 shock, followed by the compression phase of CPR, continue 5 cycles Why: There is almost a 40 second delay in analyzing the rhythm, delaying blood flow to vital organs V-fib is almost always eliminated in first shock so stacked shocks aren’t usually necessary. After shocking, it takes a few moments for a normal heart rhythm to return and more time for optimal blood flow, CPR can help increase the blood flow sooner Changed from - stacked shocks

Major Changes for EMS Definition of “Child” Tailor sequence for most likely cause Opening the Airway, Trauma Victim Check for “adequate” breathing Try a couple of times to get chest rise Excessive ventilation should not be performed

Major Changes for EMS, continued Emphasis on CPR children with HR <60bpm Compressions at adequate rate and depth Hand placement change for pediatrics Compression:Ventilation ratio changes With advanced airway no pause for breaths When 2 or more providers, rotate compressor role every 2 minutes

Definition of “Child” Change: 1 year to onset of puberty Why: Difficult to pick one anatomical or physiological characteristic that changes “child” to “adult” Changed from years

Tailor Sequence to Cause Change Adult – phone first, get AED, provide CPR Infant/Child – CPR for 2 min, phone 911, AED when available Any age- Hypoxic event, CPR for 2 min, phone 911, AED when available Why: Sudden collapse requires AED, Hypoxic event requires immediate CPR before activating 911 Change –not emphasized

Opening the Airway, Trauma Victim Change: Head tilt – chin lift unless c-spine injury is suspected Jaw thrust - if c-spine injury suspected, unless maneuver doesn’t work, then head tilt –chin lift Why: Airway is a priority Changed from - Jaw thrust only

Check for “Adequate” breathing Change: Adults -Check for “adequate” vs “normal” breathing, give 2 breaths Infant/Child – check for presence/absence of breathing, give 2 breaths if not breathing Why: No need to wait for apnea in adults Difficult to assess “adequate” but not “normal” breathing in pediatrics Changed from - check for adequate breathing for all victims

Chest Rise Change: Try a “couple of times” to get adequate chest rise Why: Asphyxia most common cause of cardiac arrest, need to try a “couple of times” to provide effective breaths Changed from - maneuver head to get optimal airway opening

Excessive Ventilation Change: Give breath over 1 second, with just enough force to get chest rise Why: Less ventilation than normal needed during CPR During CPR blood flow to lungs is 25% of normal, requiring less oxygen Hyperventilation decreases blood return to heart and can cause gastric distention Changed from seconds, large breaths

CPR for peds HR<60bpm Change: Despite adequate ventilatory support, HR remains<60bpm, if so, begin CPR Why: Bradycardia is a common terminal rhythm in children Change –not emphasized

Adequate Rate and Depth Change: Push Hard, Push Fast, allow recoil Limit interruptions to 10 seconds Why: More effective chest compressions Increased cardiac output Better blood flow Changed from -no emphasis on recoil

Hand Placement Change: Children – heel of 1 or two hands Why: Depending on child’s size, better compressions were found to be done with 2 hands Change: Infants: - 2 thumb-encircling hands technique Why: Produces higher coronary artery perfusion pressure Better depth and force of compression Generates higher systolic and diastolic pressures Changed from -1 hand in children and 2 fingers in infants

Compression:Ventilation Ratio Change: 1 rescuer – 30:2 2 rescuer – 15:2 Why: Simplify training Reduce interruptions Changed from - 5:1

Advanced Airway Change: Once an advanced airway ( ET Tube, LMA, Combitube) is in place, continuous compressions at a rate of 100/minute Why: No need to pause for breath, provides uninterrupted chest compressions Changed from - asynchronous compressions

Rotate Compressor Role Change: Rotate compressor role every 2-3 cycles Why: At the new rate compressors will tire more easily and may provide inadequate compressions Change: not emphasized

Foreign Body Obstruction Change: Intervention only applied to those with severe obstruction – (poor air exchange, increased breathing difficulty, silent cough, cyanosis, inability to speak or breathe) Why: not everyone requires intervention Change: CPR instead of abdominal thrusts Why: Previous system more complicated, CPR just as effective as abdominal thrusts Changed from - intervention if even mild symptoms, abdominal thrusts and back blows

Foreign Body Obstruction, continued Change: In an unresponsive person, every attempt to deliver breaths should start with looking in the mouth and removing object if seen. Blind finger sweeps should not be performed Why: Blind finger sweeps can result in damage to mouth or throat or to rescuer’s finger, and there is no evidence of effectiveness Changed from - blind finger sweeps in adults

What hasn’t changed? EMS Providers: BLS Checking for response Pulse check Rescue breathing without chest compressions Hand placement for adult chest compressions Compression rate Compression depth Ages used for infant BLS recommendations Defibrillation Initial dose for infants and children

NYS Protocols Adult Obstructed Airway ALWAYS: Request ALS, do not delay transport, keep patient warm If pt is conscious and can breathe, cough or speak: Do not interfere. Encourage coughing. If unable to dislodge obstruction with coughing: Admin high flow O2, transport in sitting position, If pt is conscious with signs of severe airway obstruction: Perform obstructed airway maneuvers If airway obstruction persists or pt becomes unconscious: Begin CPR, transport If airway obstruction is cleared and pt resumes breathing: Admin High flow O2, transport Changed from -continue obstructed airway maneuvers to CPR

NYS Protocols Pediatric Obstructed Airway ALWAYS: Request ALS, do not delay transport, keep patient warm, don’t agitate child, transport If pt is conscious and can breathe, cough or speak: Do not interfere, position of comfort, encourage coughing. If conscious but unable to breath, cough, speak or cry: Perform obstructed airway maneuvers If pt is unconscious or becomes unconscious & is not breathing: Establish BLS airway, remove visible foreign body, CPR, If airway obstruction is cleared and/or establishment of chest rise: Assess respiratory status, O2, assist respirations prn Changed from - continue obstructed airway maneuvers to CPR

NYS Protocols Adult Respiratory Arrest/Failure ALWAYS: Request ALS, do not delay transport, keep patient warm Inadequate ventilatory status: OPA (or NPA) High Flow O2 with BVM Rate 10-12/min, each over 1 second Tidal Volume adequate to make chest rise Changed from - without O ml over 2 seconds, or with O ml over 1-2 seconds

NYS Protocols Pediatric Respiratory Arrest/Failure ALWAYS: Request ALS, do not delay transport, keep patient warm Inadequate ventilatory status: OPA (or NPA) High Flow O2 with BVM Rate 12-20/min, each over 1 second Tidal Volume adequate to make chest rise Changed from - without O ml over 2 seconds, or with O ml over 1-2 seconds

NYS Protocols Adult & Pediatric Cardiac Arrest ALWAYS: DNR?, Request ALS, do not delay transport If apneic and pulseless: If unwitnessed or EMS arrival ≥ 4 minutes since arrest: CPR (5 cycles/2 min) prior to AED. Compressions 15:2 (2 person) If witnessed or EMS arrival < 4 minutes since arrest: AED first, then CPR prn, Compressions 15:2 (2 person) If secured advanced airway: Respiratory rate 8-10/minute, no pause in compressions If one rescuer CPR compressions at 30:2 Changed from - old compression ratio, AED first always

NYS Protocols Adult & Pediatric Cardiac Arrest, continued AED Monophasic- All shocks at 360j Biphasic – All shocks at j Pediatric – under age 8 use pediatric pads After all shocks CPR for 5 cycles/2min without checking pulse, rhythm check and/or defib. Pulse check after 5 cycles/2min or if pt appears to no longer be in cardiac arrest Max of 3 shocks on scene before transport Changed from - stacked shocks and joule settings, longer scene time

NYS Protocols Emergency Childbirth, Resuscitation and Stabilization of the Newborn ALWAYS: Request ALS, do not delay transport If newborn RR is absent or depressed (<30bpm): ventilate with high flow O2 at 40-60bpm If newborn’s HR <60 or does not increase above 60 bpm after 30 seconds of assisted ventilations: Add chest compressions at rate of 100/min and ratio of 30:2 for 1 rescuer, 15:2 for 2 rescuers Changed from - RR 30-60, HR – does not increase