H i g h l i g h t s o f t h e 2010American Heart AssociationGuidelines for CPR and ECC Contents Major Issues Affecting All...
EditorMary Fran Hazinski, RN, MSNAssociate EditorsLeon Chameides, MDRobin Hemphill, MD, MPHRicardo A. Samson, MDStephen M....
MAJOR ISSUES                                                                               MAJOR ISSUES AFFECTINGT        ...
M A J O R S C U UR S D U LT C P R    L AY R E I S S E E A    • Allowing for complete chest recoil after each compression  ...
L A Y R E S C U E R A D U LT C P R                   LAY RESCUER                                                          ...
L A Y R E S C U E R A D U LT C P R    Change in CPR Sequence: C-A-B Rather                                  Elimination of...
H E A LT H C A R E P R O V I D E R B L Sdepth is now recommended. Rescuers often do not compress             • Compression...
H E A LT H C A R E P R O V I D E R B L S    specific about the necessary components of resuscitation          2005 (Old): ...
H E A LT H C A R E P R O V I D E R B L Sis absent or not normal. The provider should suspect cardiac          of cardiac a...
H E A LT H C A R E P R O V I D E R B L S    Table 1    Summary of Key BLS Components for Adults, Children, and Infants*   ...
ELECTRICAL THERAPIES                      ELECTRICAL                                       • A planned and practiced respo...
ELECTRICAL THERAPIES     support early CPR and early defibrillation, particularly when an    Defibrillation Waveforms and ...
ELECTRICAL THERAPIESterminating VF, subsequent energy levels should be at least           may prevent VF detection (and th...
CPR TECHNIQUES AND DEVICES     2005 (Old): There was insufficient evidence to recommend a         may improve hemodynamics...
ACLS  ADVANCED CARDIOVASCULAR                                                     • Chronotropic drug infusions are recomm...
ACLS       Figure 4       Circular ACLS Algorithm                           Adult Cardiac Arrest                          ...
Highlights Huidelines 2010 CPR and ECC - AHA English
Highlights Huidelines 2010 CPR and ECC - AHA English
Highlights Huidelines 2010 CPR and ECC - AHA English
Highlights Huidelines 2010 CPR and ECC - AHA English
Highlights Huidelines 2010 CPR and ECC - AHA English
Highlights Huidelines 2010 CPR and ECC - AHA English
Highlights Huidelines 2010 CPR and ECC - AHA English
Highlights Huidelines 2010 CPR and ECC - AHA English
Highlights Huidelines 2010 CPR and ECC - AHA English
Highlights Huidelines 2010 CPR and ECC - AHA English
Highlights Huidelines 2010 CPR and ECC - AHA English
Highlights Huidelines 2010 CPR and ECC - AHA English
Highlights Huidelines 2010 CPR and ECC - AHA English
Highlights Huidelines 2010 CPR and ECC - AHA English
Highlights Huidelines 2010 CPR and ECC - AHA English
Highlights Huidelines 2010 CPR and ECC - AHA English
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Highlights Huidelines 2010 CPR and ECC - AHA English

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Highlights Huidelines 2010 CPR and ECC - AHA English

  1. 1. H i g h l i g h t s o f t h e 2010American Heart AssociationGuidelines for CPR and ECC Contents Major Issues Affecting All Rescuers 1 Lay Rescuer Adult CPR 3 Healthcare Provider BLS 5 Electrical Therapies 9 CPR Techniques and Devices 12 Advanced Cardiovascular Life Support 13 Acute Coronary Syndromes 17 Stroke 18 Pediatric Basic Life Support 18 Pediatric Advanced Life Support 20 Neonatal Resuscitation 22 Ethical Issues 24 Education, Implementation, and Teams 25 First Aid 26 Summary 28
  2. 2. EditorMary Fran Hazinski, RN, MSNAssociate EditorsLeon Chameides, MDRobin Hemphill, MD, MPHRicardo A. Samson, MDStephen M. Schexnayder, MDElizabeth Sinz, MDContributorBrenda SchoolfieldGuidelines Writing Group Chairs and CochairsMichael R. Sayre, MDMarc D. Berg, MDRobert A. Berg, MDFarhan Bhanji, MDJohn E. Billi, MDClifton W. Callaway, MD, PhDDiana M. Cave, RN, MSN, CENBrett Cucchiara, MDJeffrey D. Ferguson, MD, NREMT-PRobert W. Hickey, MDEdward C. Jauch, MD, MSJohn Kattwinkel, MDMonica E. Kleinman, MDPeter J. Kudenchuk, MDMark S. Link, MDLaurie J. Morrison, MD, MScRobert W. Neumar, MD, PhDRobert E. O’Connor, MD, MPHMary Ann Peberdy, MDJeffrey M. Perlman, MB, ChBThomas D. Rea, MD, MPHMichael Shuster, MDAndrew H. Travers, MD, MScTerry L. Vanden Hoek, MD© 2010 American Heart Association
  3. 3. MAJOR ISSUES MAJOR ISSUES AFFECTINGT his “Guidelines Highlights” publication summarizes ALL RESCUERS the key issues and changes in the 2010 American Heart Association (AHA) Guidelines forCardiopulmonary Resuscitation (CPR) and Emergency This section summarizes major issues in the 2010 AHACardiovascular Care (ECC). It has been developed for Guidelines for CPR and ECC, primarily those in basic liferesuscitation providers and for AHA instructors to focus on support (BLS) that affect all rescuers, whether healthcareresuscitation science and guidelines recommendations that providers or lay rescuers. The 2005 AHA Guidelines for CPRare most important or controversial or will result in changes in and ECC emphasized the importance of high-quality chestresuscitation practice or resuscitation training. In addition, it compressions (compressing at an adequate rate and depth,provides the rationale for the recommendations. allowing complete chest recoil after each compression, and minimizing interruptions in chest compressions). StudiesBecause this publication is designed as a summary, it does published before and since 2005 have demonstrated that (1) thenot reference the supporting published studies and does quality of chest compressions continues to require improvement,not list Classes of Recommendations or Levels of Evidence. although implementation of the 2005 AHA Guidelines for CPRFor more detailed information and references, the reader is and ECC has been associated with better CPR quality andencouraged to read the 2010 AHA Guidelines for CPR and greater survival; (2) there is considerable variation in survivalECC, including the Executive Summary,1 published online from out-of-hospital cardiac arrest across emergency medicalin Circulation in October 2010 and to consult the detailed services (EMS) systems; and (3) most victims of out-of-hospitalsummary of resuscitation science in the 2010 International sudden cardiac arrest do not receive any bystander CPR. TheConsensus on CPR and ECC Science With Treatment changes recommended in the 2010 AHA Guidelines for CPRRecommendations, published simultaneously in Circulation2 and ECC attempt to address these issues and also makeand Resuscitation.3 recommendations to improve outcome from cardiac arrestThis year marks the 50th anniversary of the first peer-reviewed through a new emphasis on post–cardiac arrest care.medical publication documenting survival after closed Continued Emphasis on High-Quality CPRchest compression for cardiac arrest,4 and resuscitationexperts and providers remain dedicated to reducing death The 2010 AHA Guidelines for CPR and ECC once againand disability from cardiovascular diseases and stroke. emphasize the need for high-quality CPR, includingBystanders, first responders, and healthcare providers allplay key roles in providing CPR for victims of cardiac arrest. • A compression rate of at least 100/min (a change fromIn addition, advanced providers can provide excellent “approximately” 100/min)periarrest and postarrest care. • A compression depth of at least 2 inches (5 cm) in adultsThe 2010 AHA Guidelines for CPR and ECC are based on and a compression depth of at least one third of the anterior-an international evidence evaluation process that involved posterior diameter of the chest in infants and childrenhundreds of international resuscitation scientists and experts (approximately 1.5 inches [4 cm] in infants and 2 incheswho evaluated, discussed, and debated thousands of peer- [5 cm] in children). Note that the range of 1½ to 2 inches isreviewed publications. Information about the 2010 evidence no longer used for adults, and the absolute depth specifiedevaluation process is contained in Box 1. for children and infants is deeper than in previous versions of the AHA Guidelines for CPR and ECC. BOX 1 Evidence Evaluation Process The 2010 AHA Guidelines for CPR and ECC are based on an extensive review of resuscitation literature and many debates and discussions by international resuscitation experts and members of the AHA ECC Committee and Subcommittees. The ILCOR 2010 International Consensus on CPR and ECC Science With Treatment Recommendations, simultaneously published in Circulation2 and Resuscitation,3 summarizes the international consensus interpreting tens of thousands of peer-reviewed resuscitation studies. This 2010 international evidence evaluation process involved 356 resuscitation experts from 29 countries who analyzed, discussed, and debated the resuscitation research during in-person meetings, conference calls, and online sessions (“webinars”) over a 36-month period, including the 2010 International Consensus Conference on CPR and ECC Science With Treatment Recommendations, held in Dallas, Texas, in early 2010. Worksheet experts produced 411 scientific evidence reviews of 277 topics in resuscitation and ECC. The process included structured evidence evaluation, analysis, and cataloging of the literature. It also included rigorous disclosure and management of potential conflicts of interest. The 2010 AHA Guidelines for CPR and ECC1 contain the expert recommendations for application of the International Consensus on CPR and ECC Science With Treatment Recommendations with consideration of their effectiveness, ease of teaching and application, and local systems factors. H i g h l i g h t s o f t h e 2 0 1 0 A H A G u i d e l i n e s f o r C PR and ECC 1 4
  4. 4. M A J O R S C U UR S D U LT C P R L AY R E I S S E E A • Allowing for complete chest recoil after each compression required to deliver the first cycle of 30 chest compressions, or approximately 18 seconds; when 2 rescuers are present for • Minimizing interruptions in chest compressions resuscitation of the infant or child, the delay will be even shorter). • Avoiding excessive ventilation Most victims of out-of-hospital cardiac arrest do not receive There has been no change in the recommendation for a any bystander CPR. There are probably many reasons for this, compression-to-ventilation ratio of 30:2 for single rescuers of but one impediment may be the A-B-C sequence, which starts adults, children, and infants (excluding newly born infants). The with the procedures that rescuers find most difficult, namely, 2010 AHA Guidelines for CPR and ECC continue to recommend opening the airway and delivering breaths. Starting with chest that rescue breaths be given in approximately 1 second. Once compressions might encourage more rescuers to begin CPR. an advanced airway is in place, chest compressions can be Basic life support is usually described as a sequence of continuous (at a rate of at least 100/min) and no longer cycled actions, and this continues to be true for the lone rescuer. with ventilations. Rescue breaths can then be provided at Most healthcare providers, however, work in teams, and about 1 breath every 6 to 8 seconds (about 8 to 10 breaths per team members typically perform BLS actions simultaneously. minute). Excessive ventilation should be avoided. For example, one rescuer immediately initiates chest A Change From A-B-C to C-A-B compressions while another rescuer gets an automated external defibrillator (AED) and calls for help, and a third rescuer opens the airway and provides ventilations. The 2010 AHA Guidelines for CPR and ECC recommend a change in the BLS sequence of steps from A-B-C (Airway, Healthcare providers are again encouraged to tailor rescue Breathing, Chest compressions) to C-A-B (Chest compressions, actions to the most likely cause of arrest. For example, Airway, Breathing) for adults, children, and infants (excluding the if a lone healthcare provider witnesses a victim suddenly newly born; see Neonatal Resuscitation section). This fundamental collapse, the provider may assume that the victim has had a change in CPR sequence will require reeducation of everyone primary cardiac arrest with a shockable rhythm and should who has ever learned CPR, but the consensus of the authors and immediately activate the emergency response system, experts involved in the creation of the 2010 AHA Guidelines for retrieve an AED, and return to the victim to provide CPR CPR and ECC is that the benefit will justify the effort. and use the AED. But for a presumed victim of asphyxial arrest such as drowning, the priority would be to provide Why: The vast majority of cardiac arrests occur in adults, chest compressions with rescue breathing for about 5 cycles and the highest survival rates from cardiac arrest are reported (approximately 2 minutes) before activating the emergency among patients of all ages who have a witnessed arrest and response system. an initial rhythm of ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT). In these patients, the critical Two new parts in the 2010 AHA Guidelines for CPR and ECC initial elements of BLS are chest compressions and early are Post–Cardiac Arrest Care and Education, Implementation, defibrillation. In the A-B-C sequence, chest compressions and Teams. The importance of post–cardiac arrest care is are often delayed while the responder opens the airway to emphasized by the addition of a new fifth link in the AHA give mouth-to-mouth breaths, retrieves a barrier device, or ECC Adult Chain of Survival (Figure 1). See the sections gathers and assembles ventilation equipment. By changing the Post–Cardiac Arrest Care and Education, Implementation, sequence to C-A-B, chest compressions will be initiated sooner and Teams in this publication for a summary of key and the delay in ventilation should be minimal (ie, only the time recommendations contained in these new parts. Figure 1 AHA ECC Adult Chain of Survival The links in the new AHA ECC Adult Chain of Survival are as follows: 1. Immediate recognition of cardiac arrest and activation of the emergency response system 2. Early CPR with an emphasis on chest compressions 3. Rapid defibrillation 4. Effective advanced life support 5. Integrated post–cardiac arrest care23 American Heart Association
  5. 5. L A Y R E S C U E R A D U LT C P R LAY RESCUER Figure 2 ADULT CPR Simplified Adult BLS Algorithm Simplified Adult BLSSummary of Key Issues and Major Changes Unresponsive No breathing orKey issues and major changes for the 2010 AHA Guidelines for no normal breathing (only gasping)CPR and ECC recommendations for lay rescuer adult CPR arethe following:• The simplified universal adult BLS algorithm has been Activate Get created (Figure 2). emergency defibrillator response• Refinements have been made to recommendations for immediate recognition and activation of the emergency response system based on signs of unresponsiveness, as Start CPR well as initiation of CPR if the victim is unresponsive with no breathing or no normal breathing (ie, victim is only gasping).• “Look, listen, and feel for breathing” has been removed from the algorithm.• Continued emphasis has been placed on high-quality CPR Check rhythm/ (with chest compressions of adequate rate and depth, shock if allowing complete chest recoil after each compression, indicated minimizing interruptions in compressions, and avoiding Repeat every 2 minutes excessive ventilation). Pu h st• There has been a change in the recommended sequence Ha a s for the lone rescuer to initiate chest compressions before giving rescue breaths (C-A-B rather than A-B-C). The lone rd • Pus hF © 2010 American Heart Association rescuer should begin CPR with 30 compressions rather than 2 ventilations to reduce delay to first compression.• Compression rate should be at least 100/min (rather than All trained lay rescuers should, at a minimum, provide chest “approximately” 100/min). compressions for victims of cardiac arrest. In addition, if• Compression depth for adults has been changed from the the trained lay rescuer is able to perform rescue breaths, range of 1½ to 2 inches to at least 2 inches (5 cm). compressions and breaths should be provided in a ratio of 30 compressions to 2 breaths. The rescuer should continueThese changes are designed to simplify lay rescuer training CPR until an AED arrives and is ready for use or EMS providersand to continue to emphasize the need to provide early chest take over care of the victim.compressions for the victim of a sudden cardiac arrest. More 2005 (Old): The 2005 AHA Guidelines for CPR and ECCinformation about these changes appears below. Note: In the did not provide different recommendations for trained versusfollowing topics, changes or points of emphasis for lay rescuers untrained rescuers but did recommend that dispatchers providethat are similar to those for healthcare providers are noted with compression-only CPR instructions to untrained bystanders.an asterisk (*). The 2005 AHA Guidelines for CPR and ECC did note that if the rescuer was unwilling or unable to provide ventilations, theEmphasis on Chest Compressions* rescuer should provide chest compressions only. Why: Hands-Only (compression-only) CPR is easier for an2010 (New): If a bystander is not trained in CPR, the bystander untrained rescuer to perform and can be more readily guidedshould provide Hands-Only™ (compression-only) CPR for by dispatchers over the telephone. In addition, survival ratesthe adult victim who suddenly collapses, with an emphasis to from cardiac arrests of cardiac etiology are similar with either“push hard and fast” on the center of the chest, or follow the Hands-Only CPR or CPR with both compressions and rescuedirections of the EMS dispatcher. The rescuer should continue breaths. However, for the trained lay rescuer who is able, theHands-Only CPR until an AED arrives and is ready for use or recommendation remains for the rescuer to perform bothEMS providers or other responders take over care of the victim. compressions and ventilations. H i g h l i g h t s o f t h e 2 0 1 0 A H A G u i d e l i n e s f o r C PR and ECC 3 4
  6. 6. L A Y R E S C U E R A D U LT C P R Change in CPR Sequence: C-A-B Rather Elimination of “Look, Listen, and Feel Than A-B-C* for Breathing”* 2010 (New): Initiate chest compressions before ventilations. 2010 (New): “Look, listen, and feel” was removed from the 2005 (Old): The sequence of adult CPR began with opening of CPR sequence. After delivery of 30 compressions, the lone the airway, checking for normal breathing, and then delivery of rescuer opens the victim’s airway and delivers 2 breaths. 2 rescue breaths followed by cycles of 30 chest compressions 2005 (Old): “Look, listen, and feel” was used to assess and 2 breaths. breathing after the airway was opened. Why: Although no published human or animal evidence demonstrates that starting CPR with 30 compressions Why: With the new “chest compressions first” sequence, CPR rather than 2 ventilations leads to improved outcome, chest is performed if the adult is unresponsive and not breathing compressions provide vital blood flow to the heart and or not breathing normally (as noted above, lay rescuers will brain, and studies of out-of-hospital adult cardiac arrest be taught to provide CPR if the unresponsive victim is “not showed that survival was higher when bystanders made breathing or only gasping”). The CPR sequence begins with some attempt rather than no attempt to provide CPR. Animal compressions (C-A-B sequence). Therefore, breathing is briefly data demonstrated that delays or interruptions in chest checked as part of a check for cardiac arrest; after the first set compressions reduced survival, so such delays or interruptions of chest compressions, the airway is opened, and the rescuer should be minimized throughout the entire resuscitation. Chest delivers 2 breaths. compressions can be started almost immediately, whereas positioning the head and achieving a seal for mouth-to-mouth Chest Compression Rate: At Least or bag-mask rescue breathing all take time. The delay in 100 per Minute* initiation of compressions can be reduced if 2 rescuers are present: the first rescuer begins chest compressions, and the 2010 (New): It is reasonable for lay rescuers and healthcare second rescuer opens the airway and is prepared to deliver providers to perform chest compressions at a rate of at least breaths as soon as the first rescuer has completed the first 100/min. set of 30 chest compressions. Whether 1 or more rescuers are present, initiation of CPR with chest compressions ensures that 2005 (Old): Compress at a rate of about 100/min. the victim receives this critical intervention early, and any delay Why: The number of chest compressions delivered per in rescue breaths should be brief. minute during CPR is an important determinant of return of spontaneous circulation (ROSC) and survival with good BOX 2 neurologic function. The actual number of chest compressions Number of Compressions Delivered delivered per minute is determined by the rate of chest Affected by Compression Rate and compressions and the number and duration of interruptions in by Interruptions compressions (eg, to open the airway, deliver rescue breaths, or allow AED analysis). In most studies, more compressions are The total number of compressions delivered during resuscitation associated with higher survival rates, and fewer compressions is an important determinant of survival from cardiac arrest. are associated with lower survival rates. Provision of adequate The number of compressions delivered is affected by the chest compressions requires an emphasis not only on an compression rate and by the compression fraction (the portion adequate compression rate but also on minimizing interruptions of total CPR time during which compressions are performed); to this critical component of CPR. An inadequate compression increases in compression rate and fraction increase the total rate or frequent interruptions (or both) will reduce the total compressions delivered, whereas decreases in compression number of compressions delivered per minute. For further rate or compression fraction decrease the total compressions information, see Box 2. delivered. Compression fraction is improved if you reduce the number and length of any interruptions in compressions, Chest Compression Depth* and it is reduced by frequent or long interruptions in chest compressions. An analogy can be found in automobile travel. 2010 (New): The adult sternum should be depressed at least 2 When you travel in an automobile, the number of miles you travel in a day is affected not only by the speed that you drive inches (5 cm). (your rate of travel) but also by the number and duration of any 2005 (Old): The adult sternum should be depressed stops you make (interruptions in travel). During CPR, you want approximately 1½ to 2 inches (approximately 4 to 5 cm). to deliver effective compressions at an appropriate rate (at least 100/min) and depth, while minimizing the number and duration Why: Compressions create blood flow primarily by increasing of interruptions in chest compressions. Additional components intrathoracic pressure and directly compressing the heart. of high-quality CPR include allowing complete chest recoil after Compressions generate critical blood flow and oxygen and each compression and avoiding excessive ventilation. energy delivery to the heart and brain. Confusion may result when a range of depth is recommended, so 1 compression4 American Heart Association
  7. 7. H E A LT H C A R E P R O V I D E R B L Sdepth is now recommended. Rescuers often do not compress • Compression depth for adults has been slightly altered to atthe chest enough despite recommendations to “push hard.” In least 2 inches (about 5 cm) from the previous recommendedaddition, the available science suggests that compressions of range of about 1½ to 2 inches (4 to 5 cm).at least 2 inches are more effective than compressions of • Continued emphasis has been placed on the need to reduce1½ inches. For this reason the 2010 AHA Guidelines for CPR the time between the last compression and shock deliveryand ECC recommend a single minimum depth for compression and the time between shock delivery and resumption ofof the adult chest. compressions immediately after shock delivery. • There is an increased focus on using a team approach during CPR. HEALTHCARE PROVIDER BLS These changes are designed to simplify training for the healthcare provider and to continue to emphasize the need toSummary of Key Issues and Major Changes provide early and high-quality CPR for victims of cardiac arrest. More information about these changes follows. Note: In theKey issues and major changes in the 2010 AHA Guidelines following topics for healthcare providers, those that are similarfor CPR and ECC recommendations for healthcare providers for healthcare providers and lay rescuers are noted withinclude the following: an asterisk (*).• Because cardiac arrest victims may present with a short Dispatcher Identification of Agonal Gasps period of seizure-like activity or agonal gasps that may confuse potential rescuers, dispatchers should be specifically Cardiac arrest victims may present with seizure-like activity or trained to identify these presentations of cardiac arrest to agonal gasps that may confuse potential rescuers. Dispatchers improve cardiac arrest recognition. should be specifically trained to identify these presentations• Dispatchers should instruct untrained lay rescuers to provide of cardiac arrest to improve recognition of cardiac arrest and Hands-Only CPR for adults with sudden cardiac arrest. prompt provision of CPR.• Refinements have been made to recommendations for 2010 (New): To help bystanders recognize cardiac arrest, immediate recognition and activation of the emergency dispatchers should ask about an adult victim’s responsiveness, response system once the healthcare provider identifies the if the victim is breathing, and if the breathing is normal, in an adult victim who is unresponsive with no breathing or no attempt to distinguish victims with agonal gasps (ie, in those normal breathing (ie, only gasping). The healthcare provider who need CPR) from victims who are breathing normally and briefly checks for no breathing or no normal breathing (ie, do not need CPR. The lay rescuer should be taught to begin no breathing or only gasping) when the provider checks CPR if the victim is “not breathing or only gasping.” The responsiveness. The provider then activates the emergency healthcare provider should be taught to begin CPR if the victim response system and retrieves the AED (or sends someone has “no breathing or no normal breathing (ie, only gasping).” to do so). The healthcare provider should not spend more Therefore, breathing is briefly checked as part of a check for than 10 seconds checking for a pulse, and if a pulse is not cardiac arrest before the healthcare provider activates the definitely felt within 10 seconds, should begin CPR and use emergency response system and retrieves the AED (or sends the AED when available. someone to do so), and then (quickly) checks for a pulse and begins CPR and uses the AED.• “Look, listen, and feel for breathing” has been removed from the algorithm. 2005 (Old): Dispatcher CPR instructions should include questions to help bystanders identify patients with occasional• Increased emphasis has been placed on high-quality CPR gasps as likely victims of cardiac arrest to increase the (compressions of adequate rate and depth, allowing complete likelihood of bystander CPR for such victims. chest recoil between compressions, minimizing interruptions in compressions, and avoiding excessive ventilation). Why: There is evidence of considerable regional variation in the reported incidence and outcome of cardiac arrest in the• Use of cricoid pressure during ventilations is generally United States. This variation is further evidence of the need for not recommended. communities and systems to accurately identify each instance• Rescuers should initiate chest compressions before giving of treated cardiac arrest and measure outcomes. It also rescue breaths (C-A-B rather than A-B-C). Beginning CPR suggests additional opportunities for improving survival rates with 30 compressions rather than 2 ventilations leads to a in many communities. Previous guidelines have recommended shorter delay to first compression. the development of programs to aid in recognition of cardiac arrest. The 2010 AHA Guidelines for CPR and ECC are more• Compression rate is modified to at least 100/min from approximately 100/min. H i g h l i g h t s o f t h e 2 0 1 0 A H A G u i d e l i n e s f o r C PR and ECC 5
  8. 8. H E A LT H C A R E P R O V I D E R B L S specific about the necessary components of resuscitation 2005 (Old): Cricoid pressure should be used only if the victim systems. Studies published since 2005 have demonstrated is deeply unconscious, and it usually requires a third rescuer improved outcome from out-of-hospital cardiac arrest, not involved in rescue breaths or compressions. particularly from shockable rhythms, and have reaffirmed the importance of a stronger emphasis on immediate provision Why: Cricoid pressure is a technique of applying pressure to of high-quality CPR (compressions of adequate rate and the victim’s cricoid cartilage to push the trachea posteriorly depth, allowing complete chest recoil after each compression, and compress the esophagus against the cervical vertebrae. minimizing interruptions in chest compressions, and avoiding Cricoid pressure can prevent gastric inflation and reduce the excessive ventilation). risk of regurgitation and aspiration during bag-mask ventilation, but it may also impede ventilation. Seven randomized studies To help bystanders immediately recognize cardiac arrest, showed that cricoid pressure can delay or prevent the dispatchers should specifically inquire about an adult placement of an advanced airway and that some aspiration victim’s absence of response, if the victim is breathing, and can still occur despite application of cricoid pressure. In if any breathing observed is normal. Dispatchers should be addition, it is difficult to appropriately train rescuers in use of specifically educated in helping bystanders detect agonal the maneuver. Therefore, the routine use of cricoid pressure in gasps to improve cardiac arrest recognition. cardiac arrest is not recommended. Dispatchers should also be aware that brief generalized Emphasis on Chest Compressions* seizures may be the first manifestation of cardiac arrest. In summary, in addition to activating professional emergency 2010 (New): Chest compressions are emphasized for responders, the dispatcher should ask straightforward both trained and untrained rescuers. If a bystander is not questions about whether the patient is responsive and trained in CPR, the bystander should provide Hands-Only breathing normally to identify patients with possible cardiac (compression-only) CPR for the adult who suddenly collapses, arrest. Dispatchers should provide Hands-Only (compression- with an emphasis to “push hard and fast” on the center of only) CPR instructions to help untrained bystanders initiate the chest, or follow the directions of the emergency medical CPR when cardiac arrest is suspected (see below). dispatcher. The rescuer should continue Hands-Only CPR Dispatcher Should Provide CPR Instructions until an AED arrives and is ready for use or EMS providers take over care of the victim. 2010 (New): The 2010 AHA Guidelines for CPR and ECC more Optimally all healthcare providers should be trained in BLS. In strongly recommend that dispatchers should instruct untrained this trained population, it is reasonable for both EMS and in- lay rescuers to provide Hands-Only CPR for adults who hospital professional rescuers to provide chest compressions are unresponsive with no breathing or no normal breathing. and rescue breaths for cardiac arrest victims. Dispatchers should provide instructions in conventional CPR for victims of likely asphyxial arrest. 2005 (Old): The 2005 AHA Guidelines for CPR and ECC did not provide different recommendations for trained and 2005 (Old): The 2005 AHA Guidelines for CPR and ECC untrained rescuers and did not emphasize differences in noted that telephone instruction in chest compressions alone instructions provided to lay rescuers versus healthcare may be preferable. providers, but did recommend that dispatchers provide compression-only CPR instructions to untrained bystanders. In Why: Unfortunately, most adults with out-of-hospital cardiac addition, the 2005 AHA Guidelines for CPR and ECC noted that arrest do not receive any bystander CPR. Hands-Only if the rescuer was unwilling or unable to provide ventilations, (compression-only) bystander CPR substantially improves the rescuer should provide chest compressions. Note that the survival after adult out-of-hospital cardiac arrests compared AHA Hands-Only CPR statement was published in 2008. with no bystander CPR. Other studies of adults with cardiac arrest treated by lay rescuers showed similar survival rates Why: Hands-Only (compression-only) CPR is easier for among victims receiving Hands-Only CPR versus those untrained rescuers to perform and can be more readily guided receiving conventional CPR (ie, with rescue breaths). by dispatchers over the telephone. However, because the Importantly, it is easier for dispatchers to instruct untrained healthcare provider should be trained, the recommendation rescuers to perform Hands-Only CPR than conventional CPR remains for the healthcare provider to perform both for adult victims, so the recommendation is now stronger compressions and ventilations. If the healthcare provider is for them to do so, unless the victim is likely to have had an unable to perform ventilations, the provider should activate the asphyxial arrest (eg, drowning). emergency response system and provide chest compressions. Cricoid Pressure Activation of Emergency Response System 2010 (New): The routine use of cricoid pressure in cardiac 2010 (New): The healthcare provider should check for arrest is not recommended. response while looking at the patient to determine if breathing6 American Heart Association
  9. 9. H E A LT H C A R E P R O V I D E R B L Sis absent or not normal. The provider should suspect cardiac of cardiac arrest. After delivery of 30 compressions, the lonearrest if the victim is not breathing or only gasping. rescuer opens the victim’s airway and delivers 2 breaths.2005 (Old): The healthcare provider activated the emergency 2005 (Old): “Look, listen, and feel for breathing” was used toresponse system after finding an unresponsive victim. The assess breathing after the airway was opened.provider then returned to the victim and opened the airway andchecked for breathing or abnormal breathing. Why: With the new chest compression–first sequence, CPR is performed if the adult victim is unresponsive and not breathingWhy: The healthcare provider should not delay activation of or not breathing normally (ie, not breathing or only gasping)the emergency response system but should obtain 2 pieces of and begins with compressions (C-A-B sequence). Therefore,information simultaneously: the provider should check the victim breathing is briefly checked as part of a check for cardiacfor response and check for no breathing or no normal breathing. arrest. After the first set of chest compressions, the airway isIf the victim is unresponsive and is not breathing at all or has no opened and the rescuer delivers 2 breaths.normal breathing (ie, only agonal gasps), the provider shouldactivate the emergency response system and retrieve the AED if Chest Compression Rate: At Least 100 per Minute*available (or send someone to do so). If the healthcare providerdoes not feel a pulse within 10 seconds, the provider should 2010 (New): It is reasonable for lay rescuers and healthcarebegin CPR and use the AED when it is available. providers to perform chest compressions at a rate of at least 100/min.Change in CPR Sequence: C-A-B RatherThan A-B-C* 2005 (Old): Compress at a rate of about 100/min. Why: The number of chest compressions delivered per2010 (New): A change in the 2010 AHA Guidelines for CPR minute during CPR is an important determinant of ROSC andand ECC is to recommend the initiation of chest compressions survival with good neurologic function. The actual number ofbefore ventilations. chest compressions delivered per minute is determined by the rate of chest compressions and the number and duration of2005 (Old): The sequence of adult CPR began with opening interruptions in compressions (eg, to open the airway, deliverof the airway, checking for normal breathing, and then delivering rescue breaths, or allow AED analysis). In most studies, delivery2 rescue breaths followed by cycles of 30 chest compressions of more compressions during resuscitation is associated withand 2 breaths. better survival, and delivery of fewer compressions is associatedWhy: Although no published human or animal evidence with lower survival. Provision of adequate chest compressionsdemonstrates that starting CPR with 30 compressions requires an emphasis not only on an adequate compression raterather than 2 ventilations leads to improved outcome, chest but also on minimizing interruptions to this critical component ofcompressions provide the blood flow, and studies of out-of- CPR. An inadequate compression rate or frequent interruptionshospital adult cardiac arrest showed that survival was higher (or both) will reduce the total number of compressions deliveredwhen bystanders provided chest compressions rather than no per minute. For further information, see Box 2 on page 4.chest compressions. Animal data demonstrate that delays orinterruptions in chest compressions reduce survival, so such Chest Compression Depth*delays and interruptions should be minimized throughout theentire resuscitation. Chest compressions can be started almost 2010 (New): The adult sternum should be depressed at least 2immediately, whereas positioning the head and achieving a inches (5 cm).seal for mouth-to-mouth or bag-mask rescue breathing all take 2005 (Old): The adult sternum should be depressed 1½ to 2time. The delay in initiation of compressions can be reduced if 2 inches (approximately 4 to 5 cm).rescuers are present: the first rescuer begins chest compressions,and the second rescuer opens the airway and is prepared to Why: Compressions create blood flow primarily by increasingdeliver breaths as soon as the first rescuer has completed the intrathoracic pressure and directly compressing the heart.first set of 30 chest compressions. Whether 1 or more rescuers Compressions generate critical blood flow and oxygen andare present, initiation of CPR with chest compressions ensures energy delivery to the heart and brain. Confusion may resultthat the victim receives this critical intervention early. when a range of depth is recommended, so 1 compression depth is now recommended. Rescuers often do not adequatelyElimination of “Look, Listen, and Feel compress the chest despite recommendations to “push hard.”for Breathing”* In addition, the available science suggests that compressions of at least 2 inches are more effective than compressions2010 (New): “Look, listen, and feel for breathing” was of 1½ inches. For this reason the 2010 AHA Guidelines for CPRremoved from the sequence for assessment of breathing after and ECC recommend a single minimum depth for compressionopening the airway. The healthcare provider briefly checks of the adult chest, and that compression depth is deeper thanfor breathing when checking responsiveness to detect signs in the old recommendation. H i g h l i g h t s o f t h e 2 0 1 0 A H A G u i d e l i n e s f o r C PR and ECC 7
  10. 10. H E A LT H C A R E P R O V I D E R B L S Table 1 Summary of Key BLS Components for Adults, Children, and Infants* Recommendations Component Adults Children Infants Unresponsive (for all ages) No breathing or no normal Recognition No breathing or only gasping breathing (ie, only gasping) No pulse palpated within 10 seconds for all ages (HCP only) CPR sequence C-A-B Compression rate At least 100/min At least ¹⁄³ AP diameter At least ¹⁄³ AP diameter Compression depth At least 2 inches (5 cm) About 2 inches (5 cm) About 1½ inches (4 cm) Allow complete recoil between compressions Chest wall recoil HCPs rotate compressors every 2 minutes Minimize interruptions in chest compressions Compression interruptions Attempt to limit interrruptions to <10 seconds Airway Head tilt–chin lift (HCP suspected trauma: jaw thrust) 30:2 Compression-to-ventilation Single rescuer 30:2 ratio (until advanced 1 or 2 rescuers airway placed) 15:2 2 HCP rescuers Ventilations: when rescuer untrained or trained and Compressions only not proficient 1 breath every 6-8 seconds (8-10 breaths/min) Ventilations with advanced Asynchronous with chest compressions airway (HCP) About 1 second per breath Visible chest rise Attach and use AED as soon as available. Minimize interruptions in chest compressions before and after shock; Defibrillation resume CPR beginning with compressions immediately after each shock. Abbreviations: AED, automated external defibrillator; AP, anterior-posterior; CPR, cardiopulmonary resuscitation; HCP, healthcare provider. *Excluding the newly born, in whom the etiology of an arrest is nearly always asphyxial. Team Resuscitation Why: Some resuscitations start with a lone rescuer who calls for help, whereas other resuscitations begin with several 2010 (New): The steps in the BLS algorithm have traditionally willing rescuers. Training should focus on building a team been presented as a sequence to help a single rescuer as each rescuer arrives, or on designating a team leader if prioritize actions. There is increased focus on providing multiple rescuers are present. As additional personnel arrive, CPR as a team because resuscitations in most EMS and responsibilities for tasks that would ordinarily be performed healthcare systems involve teams of rescuers, with rescuers sequentially by fewer rescuers may now be delegated to a team performing several actions simultaneously. For example, one of providers who perform them simultaneously. For this reason, rescuer activates the emergency response system while a BLS healthcare provider training should not only teach individual second begins chest compressions, a third is either providing skills but should also teach rescuers to work in effective teams. ventilations or retrieving the bag-mask for rescue breathing, Comparison of Key Elements of Adult, Child, and a fourth is retrieving and setting up a defibrillator. and Infant BLS 2005 (Old): The steps of BLS consist of a series of sequential assessments and actions. The intent of the algorithm is to As in the 2005 AHA Guidelines for CPR and ECC, the 2010 AHA present the steps in a logical and concise manner that will be Guidelines for CPR and ECC contain a comparison table that lists easy for each rescuer to learn, remember, and perform. the key elements of adult, child, and infant BLS (excluding CPR for newly born infants). These key elements are included in Table 1.8 American Heart Association
  11. 11. ELECTRICAL THERAPIES ELECTRICAL • A planned and practiced response, typically requiring oversight by a healthcare provider THERAPIES • Training of anticipated rescuers in CPR and use of the AEDThe 2010 AHA Guidelines for CPR and ECC have been • A link with the local EMS systemupdated to reflect new data regarding defibrillation and • A program of ongoing quality improvementcardioversion for cardiac rhythm disturbances and the use ofpacing in bradycardia. These data largely continue to support There is insufficient evidence to recommend for or against thethe recommendations in the 2005 AHA Guidelines for CPR deployment of AEDs in homes.and ECC. Therefore, no major changes were recommended In-Hospital Use of AEDsregarding defibrillation, cardioversion, and pacing. Emphasis onearly defibrillation integrated with high-quality CPR is the key to 2010 (Reaffirmed 2005 Recommendation): Despiteimproving survival from sudden cardiac arrest. limited evidence, AEDs may be considered for the hospital setting as a way to facilitate early defibrillation (a goal of shockSummary of Key Issues and Major Changes delivery ≤3 minutes from collapse), especially in areas where staff have no rhythm recognition skills or defibrillators are usedMain topics include infrequently. Hospitals should monitor collapse-to–first shock intervals and resuscitation outcomes.• Integration of AEDs into the Chain of Survival system for public places AED Use in Children Now Includes Infants• Consideration of AED use in hospitals 2010 (New): For attempted defibrillation of children 1 to 8 years of age with an AED, the rescuer should use a pediatric• AEDs can now be used in infants if a manual defibrillator is dose-attenuator system if one is available. If the rescuer not available provides CPR to a child in cardiac arrest and does not have an• Shock first versus CPR first in cardiac arrest AED with a pediatric dose-attenuator system, the rescuer should use a standard AED. For infants (<1 year of age), a manual• 1-shock protocol versus 3-shock sequence for VF defibrillator is preferred. If a manual defibrillator is not available, an AED with pediatric dose attenuation is desirable. If neither is• Biphasic and monophasic waveforms available, an AED without a dose attenuator may be used.• Escalating versus fixed doses for second and subsequent shocks 2005 (Old): For children 1 to 8 years of age, the rescuer should use a pediatric dose-attenuator system if one is• Electrode placement available. If the rescuer provides CPR to a child in cardiac arrest and does not have an AED with a pediatric attenuator• External defibrillation with implantable system, the rescuer should use a standard AED. There are cardioverter-defibrillator insufficient data to make a recommendation for or against the• Synchronized cardioversion use of AEDs for infants <1 year of age. Why: The lowest energy dose for effective defibrillation inAutomated External Defibrillators infants and children is not known. The upper limit for safe defibrillation is also not known, but doses >4 J/kg (as highCommunity Lay Rescuer AED Programs as 9 J/kg) have effectively defibrillated children and animal2010 (Slightly Modified): Cardiopulmonary resuscitation models of pediatric arrest with no significant adverse effects.and the use of AEDs by public safety first responders are Automated external defibrillators with relatively high-energyrecommended to increase survival rates for out-of-hospital doses have been used successfully in infants in cardiac arrestsudden cardiac arrest. The 2010 AHA Guidelines for CPR and with no clear adverse effects.ECC again recommend the establishment of AED programs Shock First vs CPR Firstin public locations where there is a relatively high likelihood ofwitnessed cardiac arrest (eg, airports, casinos, sports facilities). 2010 (Reaffirmed 2005 Recommendation): When anyTo maximize the effectiveness of these programs, the AHA rescuer witnesses an out-of-hospital arrest and an AED iscontinues to emphasize the importance of organizing, planning, immediately available on-site, the rescuer should start CPRtraining, linking with the EMS system, and establishing a with chest compressions and use the AED as soon as possible.process of continuous quality improvement. Healthcare providers who treat cardiac arrest in hospitals and2005 (Old): The 2005 AHA Guidelines for CPR and ECC other facilities with on-site AEDs or defibrillators should provideidentified 4 components for successful community lay rescuer immediate CPR and should use the AED/defibrillator as soonAED programs: as it is available. These recommendations are designed to H i g h l i g h t s o f t h e 2 0 1 0 A H A G u i d e l i n e s f o r C PR and ECC 9
  12. 12. ELECTRICAL THERAPIES support early CPR and early defibrillation, particularly when an Defibrillation Waveforms and Energy Levels AED or defibrillator is available within moments of the onset of sudden cardiac arrest. When an out-of-hospital cardiac arrest is 2010 (No Change From 2005): Data from both out- not witnessed by EMS personnel, EMS may initiate CPR while of-hospital and in-hospital studies indicate that biphasic checking the rhythm with the AED or on the electrocardiogram waveform shocks at energy settings comparable to or lower (ECG) and preparing for defibrillation. In such instances, 1½ than 200-J monophasic shocks have equivalent or higher to 3 minutes of CPR may be considered before attempted success for termination of VF. However, the optimal energy defibrillation. Whenever 2 or more rescuers are present, CPR for first-shock biphasic waveform defibrillation has not been should be provided while the defibrillator is retrieved. determined. Likewise, no specific waveform characteristic With in-hospital sudden cardiac arrest, there is insufficient (either monophasic or biphasic) is consistently associated with evidence to support or refute CPR before defibrillation. a greater incidence of ROSC or survival to hospital discharge However, in monitored patients, the time from VF to shock after cardiac arrest. delivery should be under 3 minutes, and CPR should be In the absence of biphasic defibrillators, monophasic performed while the defibrillator is readied. defibrillators are acceptable. Biphasic waveform shock Why: When VF is present for more than a few minutes, the configurations differ among manufacturers, and none have myocardium is depleted of oxygen and energy. A brief period been directly compared in humans with regard to their of chest compressions can deliver oxygen and energy to the relative efficacy. Because of such differences in waveform heart, increasing the likelihood that a shock will both eliminate configuration, providers should use the manufacturer’s VF (defibrillation) and be followed by ROSC. Before the recommended energy dose (120 to 200 J) for its respective publication of the 2005 AHA Guidelines for CPR and ECC, waveform. If the manufacturer’s recommended dose is not 2 studies suggested the potential benefit of CPR first rather known, defibrillation at the maximal dose may be considered. than shock first. In both studies, although 1½ to 3 minutes of Pediatric Defibrillation CPR before shock delivery did not improve overall survival from VF, the CPR-first strategy did improve survival among victims 2010 (Modification of Previous Recommendation): For with VF if the EMS call-to-arrival interval was 4 to 5 minutes pediatric patients, the optimal defibrillation dose is unknown. or longer. However, 2 subsequent randomized controlled There are limited data regarding the lowest effective dose or the trials found that CPR before attempted defibrillation by EMS upper limit for safe defibrillation. A dose of 2 to 4 J/kg may be personnel was not associated with a significant difference used for the initial defibrillation energy, but for ease of teaching, in survival to discharge. One retrospective study did find an an initial dose of 2 J/kg may be considered. For subsequent improved neurologic status at 30 days and at 1 year when shocks, energy levels should be at least 4 J/kg; higher energy immediate CPR was compared with immediate defibrillation in levels may be considered, not to exceed 10 J/kg or the adult patients with out-of-hospital VF. maximum dose. 1-Shock Protocol vs 3-Shock Sequence 2005 (Old): The initial dose for attempted defibrillation for infants and children when using a monophasic or biphasic manual defibrillator is 2 J/kg. The second and subsequent 2010 (No Change From 2005): At the time of the doses are 4 J/kg. International Liaison Committee on Resuscitation (ILCOR) 2010 International Consensus Conference on CPR and ECC Science Why: There are insufficient data to make a substantial change With Treatment Recommendations, 2 new published human in the existing recommended doses for pediatric defibrillation. studies compared a 1-shock protocol versus a 3-stacked- Initial doses of 2 J/kg with monophasic waveforms are effective shock protocol for treatment of VF cardiac arrest. Evidence in terminating 18% to 50% of VF cases, with insufficient from these 2 studies suggests significant survival benefit with a evidence to compare the success of higher doses. Case single-shock defibrillation protocol compared with a 3-stacked- reports document successful defibrillation at doses up to 9 J/kg shock protocol. If 1 shock fails to eliminate VF, the incremental with no adverse effects detected. More data are needed. benefit of another shock is low, and resumption of CPR is likely to confer a greater value than another immediate shock. This Fixed and Escalating Energy fact, combined with the data from animal studies documenting 2010 (No Change From 2005): The optimal biphasic harmful effects from interruptions to chest compressions energy level for first or subsequent shocks has not been and human studies suggesting a survival benefit from a CPR determined. Therefore, it is not possible to make a definitive approach that includes a 1-shock compared with a 3-shock recommendation for the selected energy for subsequent protocol, supports the recommendation of single shocks biphasic defibrillation attempts. On the basis of available followed by immediate CPR rather than stacked shocks for evidence, if the initial biphasic shock is unsuccessful in attempted defibrillation.10 American Heart Association
  13. 13. ELECTRICAL THERAPIESterminating VF, subsequent energy levels should be at least may prevent VF detection (and therefore shock delivery). Theequivalent, and higher energy levels may be considered, key message to rescuers is that concern about precise pad orif available. paddle placement in relation to an implanted medical device should not delay attempted defibrillation.Electrode Placement Synchronized Cardioversion2010 (Modification of Previous Recommendation):For ease of placement and education, the anterior-lateral pad Supraventricular Tachyarrhythmiaposition is a reasonable default electrode placement. Any 2010 (New): The recommended initial biphasic energy doseof 3 alternative pad positions (anterior-posterior, anterior– for cardioversion of atrial fibrillation is 120 to 200 J. The initialleft infrascapular, and anterior–right infrascapular) may be monophasic dose for cardioversion of atrial fibrillation is 200 J.considered on the basis of individual patient characteristics. Cardioversion of adult atrial flutter and other supraventricularPlacement of AED electrode pads on the victim’s bare chest in rhythms generally requires less energy; an initial energy ofany of the 4 pad positions is reasonable for defibrillation. 50 to 100 J with either a monophasic or a biphasic device is2005 (Old): Rescuers should place AED electrode pads on the often sufficient. If the initial cardioversion shock fails, providersvictim’s bare chest in the conventional sternal-apical (anterior- should increase the dose in a stepwise fashion.lateral) position. The right (sternal) chest pad is placed on the 2005 (Old): The recommended initial monophasic energyvictim’s right superior-anterior (infraclavicular) chest, and the dose for cardioversion of atrial fibrillation is 100 to 200 J.apical (left) pad is placed on the victim’s inferior-lateral left Cardioversion with biphasic waveforms is now available, butchest, lateral to the left breast. Other acceptable pad positions the optimal doses for cardioversion with biphasic waveformsare placement on the lateral chest wall on the right and left have not been established with certainty. Extrapolation fromsides (biaxillary) or the left pad in the standard apical position published experience with elective cardioversion of atrialand the other pad on the right or left upper back. fibrillation with the use of rectilinear and truncated exponentialWhy: New data demonstrate that the 4 pad positions waveforms supports an initial dose of 100 to 120 J with(anterior-lateral, anterior-posterior, anterior–left infrascapular, escalation as needed. This initial dose has been shown toand anterior–right infrascapular) appear to be equally effective be 80% to 85% effective in terminating atrial fibrillation. Untilto treat atrial or ventricular arrhythmias. Again, for ease of further evidence becomes available, this information can beteaching, the default position taught in AHA courses will not used to extrapolate biphasic cardioversion doses to otherchange from the 2005 recommended position. No studies tachyarrhythmias.were identified that directly evaluated the effect of placement Why: The writing group reviewed interim data on all biphasicof pads or paddles on defibrillation success with the endpoint studies conducted since the 2005 AHA Guidelines for CPRof ROSC. and ECC were published and made minor changes to updateDefibrillation With Implantable cardioversion dose recommendations. A number of studies attest to the efficacy of biphasic waveform cardioversionCardioverter-Defibrillator of atrial fibrillation with energy settings from 120 to 200 J,2010 (New): The anterior-posterior and anterior-lateral depending on the specific waveform.locations are generally acceptable in patients with implantedpacemakers and defibrillators. In patients with implantable Ventricular Tachycardiacardioverter-defibrillators or pacemakers, pad or paddle 2010 (New): Adult stable monomorphic VT responds well toplacement should not delay defibrillation. It might be monophasic or biphasic waveform cardioversion (synchronized)reasonable to avoid placing the pads or paddles directly over shocks at initial energies of 100 J. If there is no response to thethe implanted device. first shock, it may be reasonable to increase the dose in a step-2005 (Old): When an implantable medical device is located wise fashion. No interim studies were found that addressed thisin an area where a pad would normally be placed, position the rhythm, so the recommendations were made by writing grouppad at least 1 inch (2.5 cm) away from the device. expert consensus.Why: The language of this recommendation is a bit softer Synchronized cardioversion must not be used for treatmentthan the language used in 2005. There is the potential for of VF because the device is unlikely to sense a QRS wave,pacemaker or implantable cardioverter-defibrillator malfunction and thus, a shock may not be delivered. Synchronizedafter defibrillation when the pads are in close proximity to cardioversion should also not be used for pulseless VT orthe device. One study with cardioversion demonstrated that polymorphic VT (irregular VT).These rhythms require delivery ofpositioning the pads at least 8 cm away from the device did high-energy unsynchronized shocks (ie, defibrillation doses).not damage device pacing, sensing, or capturing. Pacemakerspikes with unipolar pacing may confuse AED software and H i g h l i g h t s o f t h e 2 0 1 0 A H A G u i d e l i n e s f o r C PR and ECC 11
  14. 14. CPR TECHNIQUES AND DEVICES 2005 (Old): There was insufficient evidence to recommend a may improve hemodynamics or short-term survival when biphasic dose for cardioversion of monomorphic VT. The 2005 used by well-trained providers in selected patients. AHA Guidelines for CPR and ECC recommended use of an 2010 (New): The precordial thump should not be used for unsynchronized shock for treatment of the unstable patient unwitnessed out-of-hospital cardiac arrest. The precordial with polymorphic VT. thump may be considered for patients with witnessed, Why: The writing group agreed that it would be helpful to add monitored, unstable VT (including pulseless VT) if a defibrillator a biphasic dose recommendation to the 2010 AHA Guidelines is not immediately ready for use, but it should not delay CPR for CPR and ECC for cardioversion of monomorphic VT but and shock delivery. wanted to emphasize the need to treat polymorphic VT as 2005 (Old): No recommendation was provided previously. unstable and as an arrest rhythm. Why: A precordial thump has been reported to convert Fibrillation Waveform Analysis to ventricular tachyarrhythmias in some studies. However, Predict Outcome 2 larger case series found that the precordial thump did not result in ROSC for cases of VF. Reported complications 2010 (No Change From 2005): The value of VF waveform associated with precordial thump include sternal fracture, analysis to guide defibrillation management during resuscitation osteomyelitis, stroke, and triggering of malignant arrhythmias is uncertain. in adults and children. The precordial thump should not delay initiation of CPR or defibrillation. Pacing CPR Devices 2010 (No Change From 2005): Pacing is not routinely recommended for patients in asystolic cardiac arrest. In Several mechanical CPR devices have been the focus of patients with symptomatic bradycardia with a pulse, it is recent clinical trials. Initiation of therapy with these devices (ie, reasonable for healthcare providers to be prepared to initiate application and positioning of the device) has the potential transcutaneous pacing in patients who do not respond to to delay or interrupt CPR for the victim of cardiac arrest, so drugs. If transcutaneous pacing fails, transvenous pacing rescuers should be trained to minimize any interruption of initiated by a trained provider with experience in central chest compressions or defibrillation and should be retrained venous access and intracardiac pacing is probably indicated. as needed. Use of the impedance threshold device improved ROSC and short-term survival in adults with out-of-hospital cardiac CPR TECHNIQUES AND DEVICES arrest, but it has not improved long-term survival in patients with cardiac arrest. Summary of Key Issues and Major Changes One multicenter, prospective, randomized controlled trial comparing load-distributing band CPR (AutoPulse®) with manual CPR for out-of-hospital cardiac arrest demonstrated To date, no CPR device has consistently been shown to be no improvement in 4-hour survival and worse neurologic superior to standard conventional (manual) CPR for out-of- outcome when the device was used. Further studies are hospital BLS, and no device other than a defibrillator has required to determine if site-specific factors and experience consistently improved long-term survival from out-of-hospital with deployment of the device could influence its efficacy. cardiac arrest. This part of the 2010 AHA Guidelines for CPR There is insufficient evidence to support the routine use of and ECC does contain summaries of recent clinical trials. this device. CPR Techniques Case series employing mechanical piston devices have reported variable degrees of success. Such devices may be Alternatives to conventional manual CPR have been considered for use when conventional CPR would be difficult developed in an effort to enhance perfusion during to maintain (eg, during diagnostic studies). resuscitation from cardiac arrest and to improve survival. Compared with conventional CPR, these techniques typically To prevent delays and maximize efficiency, initial training, require more personnel, training, and equipment, or they ongoing monitoring, and retraining programs should be apply to a specific setting. Some alternative CPR techniques offered on a frequent basis to providers using CPR devices.12 American Heart Association
  15. 15. ACLS ADVANCED CARDIOVASCULAR • Chronotropic drug infusions are recommended as an alternative to pacing in symptomatic and unstable bradycardia. LIFE SUPPORT • Adenosine is recommended as safe and potentially effective for both treatment and diagnosis in the initialSummary of Key Issues and Major Changes management of undifferentiated regular monomorphic wide- complex tachycardia.The major changes in advanced cardiovascular life support • Systematic post–cardiac arrest care after ROSC should(ACLS) for 2010 include the following: continue in a critical care unit with expert multidisciplinary• Quantitative waveform capnography is recommended for management and assessment of the neurologic and confirmation and monitoring of endotracheal tube placement physiologic status of the patient. This often includes the use and CPR quality. of therapeutic hypothermia.• The traditional cardiac arrest algorithm was simplified and an Capnography Recommendation alternative conceptual design was created to emphasize the importance of high-quality CPR. 2010 (New): Continuous quantitative waveform capnography• There is an increased emphasis on physiologic monitoring to is now recommended for intubated patients throughout the optimize CPR quality and detect ROSC. periarrest period. When quantitative waveform capnography is used for adults, applications now include recommendations• Atropine is no longer recommended for routine use in the for confirming tracheal tube placement and for monitoring CPR management of pulseless electrical activity (PEA)/asystole. quality and detecting ROSC based on end-tidal carbon dioxide (PETCO2) values (Figures 3A and 3B). Figure 3 Capnography Waveforms 1-minute interval 50 mm Hg 37.5 25 12.5 0 Before intubation Intubated A. Capnography to confirm endotracheal tube placement. This capnography tracing displays the partial pressure of exhaled carbon dioxide (PETCO2) in mm Hg on the vertical axis over time when intubation is performed. Once the patient is intubated, exhaled carbon dioxide is detected, confirming tracheal tube placement. The PETCO2 varies during the respiratory cycle, with highest values at end-expiration. 1-minute interval 50 mm Hg 37.5 25 12.5 0 CPR ROSC B. Capnography to monitor effectiveness of resuscitation efforts. This second capnography tracing displays the PETCO2 in mm Hg on the vertical axis over time. This patient is intubated and receiving CPR. Note that the ventilation rate is approximately 8 to 10 breaths per minute. Chest compressions are given continuously at a rate of slightly faster than 100/min but are not visible with this tracing. The initial PETCO2 is less than 12.5 mm Hg during the first minute, indicating very low blood flow. The PETCO2 increases to between 12.5 and 25 mm Hg during the second and third minutes, consistent with the increase in blood flow with ongoing resuscitation. Return of spontaneous circulation (ROSC) occurs during the fourth minute. ROSC is recognized by the abrupt increase in the PETCO2 (visible just after the fourth vertical line) to over 40 mm Hg, which is consistent with a substantial improvement in blood flow. H i g h l i g h t s o f t h e 2 0 1 0 A H A G u i d e l i n e s f o r C PR and ECC 13
  16. 16. ACLS Figure 4 Circular ACLS Algorithm Adult Cardiac Arrest CPR Quality •    ush hard (≥2 inches [5 cm]) and fast (≥100/min) and allow complete  P chest recoil •    inimize interruptions in compressions M Shout for Help/Activate Emergency Response •    void excessive ventilation A •    otate compressor every 2 minutes R •   f no advanced airway, 30:2 compression-ventilation ratio I •    uantitative waveform capnography  Q Start CPR –   f Petco2 <10 mm Hg, attempt to improve CPR quality I • Give oxygen •   ntra-arterial pressure  I • Attach monitor/defibrillator –   f relaxation phase (diastolic) pressure <20 mm Hg, attempt to  I Return of Spontaneous improve CPR quality 2 minutes Circulation (ROSC) Return of Spontaneous Circulation (ROSC) •    ulse and blood pressure P Check Post–Cardiac •    brupt sustained increase in Petco2 (typically ≥40 mm Hg) A Rhythm Arrest Care •    pontaneous arterial pressure waves with intra-arterial monitoring S If VF/VT Shock Shock Energy • Biphasic: Manufacturer recommendation (120-200 J); if unknown,  Drug Therapy use maximum available. Second and subsequent doses should be  equivalent, and higher doses may be considered. tinuous CPR IV/IO access Co Epinephrine every 3-5 minutes •  Monophasic: 360 J ntinu us CPR Amiodarone for refractory VF/VT Drug Therapy • Epinephrine IV/IO Dose: 1 mg every 3-5 minutes •    asopressin IV/IO Dose: 40 units can replace first or second dose  V o Consider Advanced Airway of epinephrine Quantitative waveform capnography • Amiodarone IV/IO Dose: First dose: 300 mg bolus. Second dose: 150 mg. on Advanced Airway •    upraglottic advanced airway or endotracheal intubation S C Treat Reversible Causes •    aveform capnography to confirm and monitor ET tube placement  W •    -10 breaths per minute with continuous chest compressions 8 Mo y n it o r C R Q u a lit Reversible Causes –  Hypovolemia –  Tension pneumothorax P –  Hypoxia –  Tamponade, cardiac –  Hydrogen ion (acidosis) –  Toxins –  Hypo-/hyperkalemia –  Thrombosis, pulmonary –  Hypothermia –  Thrombosis, coronary 2005 (Old): An exhaled carbon dioxide (CO2) detector or an in the patient with ROSC also causes a decrease in PETCO2. In esophageal detector device was recommended to confirm contrast, ROSC may cause an abrupt increase in PETCO2. endotracheal tube placement. The 2005 AHA Guidelines for CPR and ECC noted that PETCO2 monitoring can be useful as a Simplified ACLS Algorithm and New Algorithm noninvasive indicator of cardiac output generated during CPR. 2010 (New): The conventional ACLS Cardiac Arrest Why: Continuous waveform capnography is the most reliable Algorithm has been simplified and streamlined to emphasize method of confirming and monitoring correct placement of the importance of high-quality CPR (including compressions an endotracheal tube. Although other means of confirming of adequate rate and depth, allowing complete chest recoil endotracheal tube placement are available, they are not more after each compression, minimizing interruptions in chest reliable than continuous waveform capnography. Patients are compressions, and avoiding excessive ventilation) and the fact at increased risk of endotracheal tube displacement during that ACLS actions should be organized around uninterrupted transport or transfer; providers should observe a persistent periods of CPR. A new circular algorithm is also introduced capnographic waveform with ventilation to confirm and monitor (Figure 4, above). endotracheal tube placement. 2005 (Old): The same priorities were cited in the 2005 AHA Because blood must circulate through the lungs for CO2 to Guidelines for CPR and ECC. The box and arrow algorithm be exhaled and measured, capnography can also serve as a listed key actions performed during the resuscitation in a physiologic monitor of the effectiveness of chest compressions sequential fashion. and to detect ROSC. Ineffective chest compressions (due to either patient characteristics or rescuer performance) are Why: For the treatment of cardiac arrest, ACLS interventions associated with a low PETCO2. Falling cardiac output or rearrest build on the BLS foundation of high-quality CPR to increase14 American Heart Association

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