Transcript 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

Planned, practiced response with CPR/AEDs
yields survival rates of 49-74%
What Have We Learned About CPR?
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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!
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Too slow
Too shallow
No CPR x 24-49% of the arrest!
Most significant changes 2005
IT’S ALL ABOUT BLOOD FLOW!
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Emphasis on effective CPR
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Fast; deep; 50/50; minimal interruption
Single compression-to-ventilation ratio
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30:2 single rescuer adult, child, infant, excluding
newborns
Most significant changes (cont.)
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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?
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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?
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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?
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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
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2005 (New):
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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
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2000 (Old):
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Less emphasis was given to need for adequate
depth, complete chest recoil, and minimizing
interruptions
Chest Compressions cont’d
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Why:
 If chest not allowed to recoil:
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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
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Why:
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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
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2005 (New):
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2000 (Old):
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If more than 1 rescuer present, change “compressor” roles
every 2 minutes
Rescuers changed when fatigued-usually did not report
feeling fatigued until 5min. or more
Why:
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In manikin studies, rescuer fatigue developed in as little as
1-2minutes(as demonstrated by inadequate chest
compressions)
Rescue Breathing without
Compressions
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2005 (New):
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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):
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10-12 breaths for adults
20 breaths for infant or child
Rescue Breathing without
Compressions cont’d
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Why:
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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
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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 500-600ml
2000 (Old):
 Rescue breaths over 1-2 seconds
 Recommended tidal volume for adult rescue
breaths was 700ml-1000ml
Rescue Breaths with Compressions
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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 , initial
oxygen content in blood adequate/ cardiac
output is reduced
 Effective chest compressions more
important than rescue breaths immediately
after VF
Rescue Breaths with Compressions
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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
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Why:
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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
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2005 (New):
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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
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2000 (Old):
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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
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Why:
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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
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2005 (New):
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In patients with suspected cervical spine injuries-if
unable to open airway using the jaw thrust, use
the head-tilt chin lift
2000 (Old):
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Jaw thrust without head tilt taught to both lay
rescuers and healthcare providers
Airway/Trauma Victims
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Why:
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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
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2005 (New):
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BLS healthcare provider checks for:
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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
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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
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2005 (New):
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Attempt “a couple of times” to deliver 2 effective
breaths (that cause visible chest rise)
2000 (Old):
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Healthcare providers were taught to move head
through a variety of positions to obtain optimal
airway opening
Infant/Child: Give 2 Effective
Breaths
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Why:
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Most common mechanism of cardiac arrest in
infants and children is asphyxial
Rescuer must be able to provide effective breaths
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Lone Healthcare Provider-”phone
first” vs. “CPR first”
2005 (New):
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Tailor sequence to most likely cause of
cardiac arrest
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“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
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2000 (Old): Tailoring response to likely cause
of arrest was not emphasized in training
Why:
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Sudden collapse-likely cardiac and early CPR and
defibrillation needed
Victims of hypoxic arrest need immediate CPR
“Child” BLS Guidelines
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2005 (New):
 Child CPR guidelines for healthcare providers
apply to victims from 1 year of age to onset
puberty (about 12-14 years old)
2000 (Old):
 Child CPR age 1-8
“Child” BLS
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Why:
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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
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2005 (New):
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Chest compressions indicated if HR <60 and
signs of poor perfusion, despite adequate
ventilation
2000 (Old):
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Same recommendation in 2000 guidelines but it
was not incorporated into the BLS training
Symptomatic Bradycardia
Infants/Children cont’d
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Why:
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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
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2005 (New):
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2000 (Old):
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Use heel of 1 or 2 hands
Use heel of 1 hand
Why:
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Child manikin study showed that rescuers
performed better chest compressions using the
“adult” technique
Infant Chest Compressions
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2005 (New):
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2000 (Old):
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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:
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This technique results in higher coronary artery
perfusion pressure
Compression to Ventilation Ratios
Infants/Children
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2005 (New):
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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):
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15:2 adults
5:1 infants/children
Compression to Ventilation Ratios
Infants/Children
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Why:
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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
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2005 (New):
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Airway obstructions classified as mild or
severe
Rescuers should act only if signs of
severe obstruction present
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poor air exchange
Increased respiratory distress
Silent cough
Cyanosis
Inability to speak or breath
Foreign Body Airway Obstruction
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2005 (New)
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If victim becomes unresponsive
 ACTIVATE 9-1-1 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
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2000 (Old):
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Rescuers taught to recognize
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Rescuers taught to ask 2 questions
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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
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Why:
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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
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2005 (New):
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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
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2000 (Old):
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3 stacked shocks recommended
Why:
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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
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2005 (New):
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2000 (Old):
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Initial and subsequent shocks for VF/pulseless VT
in adults 360J
200, 200-300J, 360J
Why:
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One dose to simplify training
Biphasic Defibrillation Dose
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2005 (New):
Initial shock for adults:150-200J 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
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Biphasic Defibrillation Dose cont’d
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2000 (Old):
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200J, 200-300J, 360J
Why:
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Simplify defibrillation
Support use of device-specific doses
Use of AED’s in Children
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2005 (New):
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2000 (Old):
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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:
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Evidence published since 2000 shows AED’s
safe and effective for use in infants and
children
Community/Lay Rescuer AED Programs
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2005 (New):
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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):
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Key elements of an AED program included:
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Physician oversight
Training of rescuers
Integration with EMS
Process of CQI
Community/Lay Rescuer AED
Programs cont’d
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2005 (Why):
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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