| 2010 AHA Guidelines for CPR & ECC - ACLS |
| Changes translate science into survival Key changes: Good BLS remains the foundation for ACLS CPR sequence changed to Compressions Airway Breathing Why? · Reduce delay to start of CPR · Emphasizes the primary importance of compressions · No equipment needed for compressions · Ventilations are only delayed 18 seconds or less (child delayed 9 seconds) · Maintain oxygen and substrate delivery to the brain and heart When effective during a VFib arrest: · Makes “good (coarse)” VF last longer · Heart more likely to respond to shock if coarse VF Universal Algorithm for arrest requires 2 minutes of uninterrupted CPR Why? · Coronary perfusion pressure (CPP) is linked to survival; interruptions in CPR decrease CPP Hands only CPR reaffirmed · Nationally less than 30% of arrested patients get CPR · 69% family members won’t do CPR! · 3 observational studies –no difference in survival in Bystander Hands only CPR vs. Conventional CPR · No CPR vs some CPR- survival doubled with any attempted CPR Compression Depth at least 2 inches Why? · More effective depth than 1.5 inches –improved ROSC (Return of Spontaneous Circulation) · Studies show rescuers don’t push hard enough · Confusion if a range is given Compression Rate at least 100 minute Number of compressions linked to survival – rate >90 improves survival No look, listen and feel Why? · Rescuers think gasping is effective and fail to start CPR (wording now is if “no normal breathing” start CPR beginning with compressions · Health Care Providers will look for breathing during pulse check · Starting CPR with compressions has a minimum delay to action · (Note: all pediatric arrest have compressions and ventilation recommended; 2 minutes of CPR before calling if lone rescuer unless sudden collapse then call first) New CAB sequence for HCP: Recognize unresponsiveness, no normal breathing Activate 911/Call for AED Pulse check <10 seconds No pulse, begin 30 compressions and 2 breaths Use AED as soon as available Need a cohesive team performance for successful resuscitation systems Resuscitation systems must do continuous quality improvement Providers will need refreshers to maintain “credential” Electrical Therapy ü Pre-shock pause (time from stop compressions to shock delivered) affects shock success (<10 seconds pause had 94% success rate; 40 second pause had 38% success rate) ü Adult defibrillation dose unchanged – 120-200 joules biphasic ü Insufficient date for escalation of joules for VFib/pulseless VT ü Recommendations for adult cardioversion doses for biphasic units given ü In-hospital AED goal – shock within 3 minutes of arrest ü Folks need to practice to decrease interruptions associated with shock and minimize pre-shock pause ü There are now four positions appropriate for paddle/lead placement – anterior/lateral, anterior/ posterior, left anterior/left scapular, right anterior/infrascapular Airway Management · No data to support passive oxygen delivery during CPR for still have ventilation in CPR · Oxygen toxicity unlikely, so 100% OK for resuscitation · With ACS care only need to maintain oxygen sats at 94% unless respiratory distress · Stopping CPR for early advanced airway placement is unnecessary- don’t intubate ASAP but focus on critical part of providing CPP- compressions come first · Bag Valve device not recommended for one person CPR (time waster to get seal)- use mouth to mask; BVM best with 3 person CPR · Ventilations volume-enough to make chest rise over 1 second · Avoid routine use of cricoid pressure during cardiac arrest · Increased emphasis on supraglottic devices with blind insertion (LMA, Combitube and Laryngeal tube –King) as acceptable alternative to Bag Valve breathing · No studies address timing of advanced airway or sequencing and survival but not a priority · Endotracheal tubes require practice/competency; team training for 10 second interruption in CPR only · Confirmation of ET or supraglottic tube placement- Auscultation with observation of chest rise and fall or direct visualization of tube through cords are as accurate or perhaps more accurate than exhaled CO2 detectors · Continuous capnography is recommended since it can– check tube placement AND optimize quality of CPR performance AND confirm ROSC ACLS Algorithms Still only things that make a difference in survival are CPR and early defibrillation! · There are 2 simpler algorithms for arrest –standard box algorithm and new algorithm with circle to emphasize importance of continuous CPR · Lidocaine, although not on the algorithm is not gone; Amiodarone is preferred so it is the only antiarrhythmic listed on the revised algorithm · Monitor CPR quality is part of the circular algorithm – recommend continuous capnography or art line (quantitative trending to monitor quality –the higher the better the CPR and better chance for ROSC) · Hypoglycemia and Trauma have been removed from the H’s and T’s list · H’s and T’s are with every algorithm · It’s all about high quality CPR - no compression = no blood flow= lose myocardial and brain cells · De-emphasize Devices, Drugs and other distractors a. Mechanical devices –LUCAS mechanical piston no studies to compare use with CPR and survival; AutoPulse load distributing band had worse neurologic outcomes and decreased survival therefore insufficient evidence to support routine use b. ResQPod impedence threshold device – did increase ROSC and short term survival but no improvement in long term survival or neurologic outcomes; may be considered. c. Precordial Thump – is back for in hospital witnessed and monitored VF/unstable VT arrest with no defib on hand · Atropine has been removed from the Asystole/PEA algorithms · Adenosine –now on Tachy algorithm as diagnostic for stable monmorhphic wide complex tachycardia with aberrant conduction (if SVT will break rhythm, if VT will have no effect on rhythm); do not use for irregular WCT · Chronotropic agents are an alternate to pacing for symptomatic bradycardias. · Use of Sodium Bicarbonate or Calcium are not recommended New 5th Link in the Chain of Survival – Post Arrest Care Post Arrest Care - based on a “bundle of care” and protocols to set stage for care of patient after cardiac arrest · Treat reversible causes ( early 12 lead EKG to check for STEMI, PCI if needed) · Therapeutic Hypothermia – Cool 32-34 degrees C for 12-24 hours; if cold do not rewarm; avoid fever · Optimize ventilation (FIO2 to maintain arterial oxygen sat at 94% and PCO2 40-45mmHg) · Optimize BP – target MAP 65mmHg · Glucose control – moderate control to maintain glucose 144 -180; avoid controlling to a lower range · Perform EEG to check for seizures; treat if present · Neuro prognostication –consider >72 hours after ROSC to predict outcome with multiple measures if hypothermia used · When bundle/systems of care used, patient outcomes improve 56% to survival with good neuro status ACS/Stroke/Other · New conditions addressed in Special Resuscitation chapter –morbid obesity, Pulmonary Embolism · ACS- don’t need oxygen if O2 sat >94 · ACS – use of Morphine in unstable angina/non-stemi have increased mortality · Stroke- window for fibrinolytics increased to 4.5 hours with added countraindications; not FDA approved · Stroke – algorithm now has 8 D’s · Education- teamwork skills are needed to ensure minimum interruption of high quality CPR · Learner focused, non-threatening defriefing can be a valuable tool · New CPR feedback and prompt devices may be useful for CPR training; their use in clinical settings has not been studied Rollout of new guidelines to instructor- Instructors registered on the instructor network will receive an email with link to online instructor update. Notices to instructors will not all be sent out at the same time since there are 275,000 instructors on the network. Anticipate notices beginning to be sent the end of November. Order – notices will be sent first to Regional Faculty then instructors. Instructors may also attend the ECCU pre-conference in SanDiego in December. Instructors should not be teaching the new material until they have completed the online update and obtained the interim teaching materials listed below. Interim training materials will be posted on the instructor network and will include: ü 22 minute Science Update Video which instructors will download and use for all ACLS classes ü C-A-B sequence video to download and use for all ACLS classes ü Errata sheet for ACLS provider manual (lists changes so students can use the 2006 Provider Manual until the 2010 ACLS manuals are release) for each student ü 2010 skills sheets for each student Instructors should obtain for themselves and each student taking an ACLS class a 2010 ECC Handbook (currently available from vendors). Use of The 2010 AHA Guidelines for CPR and ECC is optional but instructors should definitely have and read the ACLS portion. These are currently available from vendors. Each student will still need a 2006 ACLS Provider Manual until the new books are available (anticipate 2011 second quarter release for all ACLS products). Lesson map changes (where to include the new information to update current classes are also available. Tests for ACLS will be released to your Training Center, so you will need to contact your training center about getting these when you begin using the interim training materials.. |
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