2005 AHA Guideline Changes

BLS for Healthcare Providers

Purpose of BLS Changes

To improve survival from cardiac arrest by increasing the number of victims of cardiac arrest who receive early, high-quality CPR

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

What Have We Learned About CPR?

330,000 die annually from coronary heart disease CDC

60% from SCA @ home or en route85-90% in VF/VT arrest2-3 x greater survival if CPR is immediate, with defib <5 min.EMS relies on trained, willing, equipped public

Less than 1/3 get bystander CPREven pros don’t do good CPR!

Too slow

Too shallow

No CPR x 24-49% of the arrest!

Most significant changes 2005

IT’S ALL ABOUT BLOOD FLOW!

Emphasis on effective CPRFast; deep; 50/50; minimal interruption

Single compression-to-ventilation ratio30:2 single rescuer adult, child, infant,

excluding newborns

Most significant changes (cont.)

Each shock from an AED should be followed by 2 minutes of CPR (5 cycles of 30:2) starting with compressions

Each rescue breath should take one second and produce visible chest rise

Reaffirmation that AEDs should be used for kids 1-8 y.o.

Why change compressions?

When compressions stop, blood flow stops!

Universal compression ratio easier to learn/retain

Higher ratio yields more blood flow; keeps pump “primed”

Why shorten breaths?

Large volume breaths increase ITP; decrease venous return to heart

Long breaths interrupt compressions

Hyperventilation decreases coronary and cerebral perfusion pressures

Over-ventilation increases air in stomach; regurgitation/aspiration

Why from 3 shocks to 1?

Biphasic defibrillators eliminate VF 85% on first shock

Current AED sequence can delay CPR 37 seconds

Long CPR interruptions decrease likelihood of subsequent successful shocks

Myocardial “stunning” (O2, ATP depletion)

Chest Compressions

2005 (New): Push hard, fast, rate of 100 per minuteAllow full chest recoil after each

compressionMinimize interruptions (no more than 10

seconds at a time) except for specific interventions (advanced airway/AED)

Chest Compressions cont’d

2000 (Old):Less emphasis was given to need for

adequate depth, complete chest recoil, and minimizing interruptions

Chest Compressions cont’dWhy: If chest not allowed to recoil:

less venous return to heart reduced filling of heartDecreased cardiac output for subsequent chest

compressionsWhen chest compressions are interrupted,

blood flow stops and coronary artery perfusion pressure falls

Chest Compressions cont’d

Why: Study of CPR performed by healthcare

providers found that:½ of chest compressions too shallowNo compressions provided during 24%

to 49% of CPR time

Changing Compressors Every 2 Minutes

2005 (New): If more than 1 rescuer present, change

“compressor” roles every 2 minutes

2005 (Old): Rescuers changed when fatigued-usually did not

report feeling fatigued until 5min. or more

Why: In manikin studies, rescuer fatigue developed in as

little as 1-2minutes(as demonstrated by inadequate chest compressions)

Rescue Breathing without Compressions

2005 (New):10-12 breaths per minute (adults) 1 every

5-6 seconds12-20 breaths per minute for infant or child

1 every 3-5 seconds

2000 (Old):10-12 breaths for adults20 breaths for infant or child

Rescue Breathing without Compressions cont’d

Why:Wider range of acceptable breaths for

infant and child will allow the provider to tailor support to patient

Note: If you are assisting lay rescuer-they are not taught to deliver rescue breaths without chest compression

Rescue Breaths with Compressions

2005 (New): Each rescue breath should be given over 1

second and produce visible chest riseAvoid breaths that are too large or too

forcefulManikins configured so that visible chest rise

occurs at 500-600ml2000 (Old):Rescue breaths over 1-2 secondsRecommended tidal volume for adult rescue

breaths was 700ml-1000ml

Rescue Breaths with Compressions cont’d

Why:Oxygen Delivery

Oxygen delivery is product of oxygen content in the arterial blood and cardiac output (blood flow)

During first minutes of CPR for VF SCA, initial oxygen content in blood adequate/ cardiac output is reduced

Effective chest compressions more important than rescue breaths immediately after VF SCA

Rescue Breaths with Compressions cont’d

Why:Ventilation-Perfusion Ratio

The best oxygenation of blood and elimination of CO2 occur when ventilation (volume of breaths x rate) closely matches perfusion

During CPR , blood flow to lungs is about 25-33% of normal

Less ventilations needed during cardiac arrest than when patient has perfusing rhythm

Rescue Breaths with Compressions cont’d

Why:Hyperventilation leads to:

Increased positive pressure in the chestDecreased venous return to the heartLimited refilling of heartDecreased cardiac output during

subsequent compressionsGastric distention/vomiting

2 Rescuer CPR with Advanced Airway

2005 (New):No pause for ventilation when there is an

advanced airway in place8-10 breaths per minute

2 Rescuer CPR with Advanced Airway cont’d

2000 (Old):Recommended “asynchronous”

compressions and ventilationsVentilation rate of 12-15 per minuteRescuers taught to re-check for signs of

circulation “every few minutes”

2 Rescuer CPR with Advanced Airway cont’d

Why:Ventilations can be delivered during

compressionsAvoid excessive number of breathsDuring CPR, blood flow to lungs

decreased, so lower than normal respiratory rate will maintain adequate oxygenation

Airway/Trauma Victims

2005 (New): In patients with suspected cervical spine

injuries-if unable to open airway using the jaw thrust, use the head-tilt chin lift

2000 (Old): Jaw thrust without head tilt taught to both

lay rescuers and healthcare providers

Airway/Trauma Victims cont’d

Why:Jaw thrust difficult maneuver to learn,may not

effectively open airway and it can cause spinal movement

Opening the airway is a priority in an unresponsive trauma victim

Manual stabilization preferred over immobilization devices during CPR

“Adequate” vs.Presence or Absence of Breathing

2005 (New): BLS healthcare provider checks for: adequate breathing in adult victims presence or absence of breathing in children

and infants

Advanced healthcare provider (with ACLS and PALS/PEPP) will assess for adequate breathing in victims of all ages

Adequate vs. Presence or Absence of Breathing cont’d2000 (Old):Healthcare provider checked for adequate

breathing for victims of all agesWhy:Children may demonstrate breathing

patterns (rapid, grunting) which are adequate but not normal

Assessment for adequate breathing is more consistent with advanced provider skill

Infant/Child: Give 2 Effective Breaths

2005 (New):Attempt “a couple of times” to deliver 2

effective breaths (that cause visible chest rise)

2000 (Old):Healthcare providers were taught to move

head through a variety of positions to obtain optimal airway opening

Infant/Child: Give 2 Effective Breaths cont’d

Why: Most common mechanism of cardiac arrest

in infants and children is asphyxial Rescuer must be able to provide effective

breaths

Lone Healthcare Provider-”phone first” vs.

“CPR first”2005 (New): Tailor sequence to most likely

cause of cardiac arrest“Phone First” Sudden witnessed collapse

(adult or child)-likely to be cardiac in origin. Call 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 cont’d

2000 (Old): Tailoring response to likely cause of arrest was not emphasized in training

Why: Sudden collapse-likely cardiac and early

CPR and defibrillation neededVictims of hypoxic arrest need immediate

CPR

“Child” BLS Guidelines

2005 (New):Child CPR guidelines for healthcare

providers apply to victims from 1 year of age to onset puberty (about 12-14 years old)

2000 (Old):Child CPR age 1-8

“Child” BLS cont’d

Why: No single anatomic or physiologic

characteristic that distinguishes a “child” victim from an “adult” victim

No scientific evidence that identifies a precise age to begin adult techniques

Symptomatic BradycardiaInfants/Children

2005 (New): Chest compressions indicated if HR <60

and signs of poor perfusion, despite adequate ventilation

2000 (Old):Same recommendation in 2000 guidelines

but it was not incorporated into the BLS training

Symptomatic BradycardiaInfants/Children cont’d

Why:Bradycardia is common terminal rhythm in

infants and children

Do not want to wait for development of pulseless arrest to begin chest compressions if there are signs of poor perfusion and no improvement with 02 and ventilatory support

Child Chest Compressions

2005 (New): Use heel of 1 or 2 hands

2000 (Old): Use heel of 1 hand

Why:Child manikin study showed that rescuers

performed better chest compressions using the “adult” technique

Infant Chest Compressions2005 (New):Use the 2 thumb-encircling technique-

sternum compressed with thumbs and use fingers to squeeze thorax

2000 (Old):Use of fingers to compress chest wall was

not described

Why:This technique results in higher coronary

artery perfusion pressure

Compression to Ventilation Ratios Infants/Children

2005 (New):Lone rescuer:Compression to ventilation

ratio 30:2 for infants, children and adults for

2 Rescuer CPR: 15:2 ratio for infants and children

2000 (Old):15:2 adults 5:1 infants/children

Compression to Ventilation Ratios Infants/Children cont’d

Why:Simplify trainingReduce interruptions in chest

compressions15:2 ratio for 2 rescuer CPR for

infants/children will provide additional ventilations

Foreign Body Airway Obstruction2005 (New):Airway obstructions classified as mild

or severeRescuers should act only if signs

of severe obstruction presentpoor air exchange Increased respiratory distressSilent coughCyanosis Inability to speak or breath

Foreign Body Airway Obstruction cont’d

2005 (New) cont’d If victim becomes unresponsive

ACTIVATE 9-1-1 and begin CPRWhen airway opened during CPR, look

in mouth and remove object if seenNo blind finger sweeps

Foreign Body Airway Obstruction cont’d

2000 (Old):Rescuers taught to recognize

Partial obstruction with good air exchangePartial obstruction with poor air exchangeComplete airway obstruction

Rescuers taught to ask 2 questionsAre you choking?Can you speak?

Sequence for unresponsive choking victim was a complicated sequence/included abdominal thrusts

Foreign Body Airway Obstruction cont’d

Why:SimplificationCompressions during CPR may increase

intrathoracic pressure more than abdominal thrusts

Blind finger sweeps may injure victims mouth/throat or rescuers finger

Shock /Immediate CPR

2005 (New):Delivery of single shock for VF and

pulseless VT followed by immediate CPRPerform 2 minutes of CPR before checking

for signs of circulation

Shock /Immediate CPR cont’d2000 (Old):3 stacked shocks recommended

Why:3 shocks were based on use of

monophasic waveformsNew biphasic defibrillators have a higher

first-shock success rate3-shock sequence can result in delays up

to 37 seconds or longer from delivery of shock and delivery of first post-shock compression

Monophasic Defibrillation dose

2005 (New): Initial and subsequent shocks for

VF/pulseless VT in adults 360J

2000 (Old):200, 200-300J, 360J

Why: One dose to simplify training

Biphasic Defibrillation Dose

2005 (New): Initial shock for adults:150-200J for

biphasic truncated exponential waveform120J for rectilinear biphasic waveformThe second dose should be the same or

higher Rescuers should use the device-specific

defibrillation dose. If rescuer unfamiliar with device-specific dose-use default dose of 200J

Biphasic Defibrillation Dose cont’d

2000 (Old): 200J, 200-300J, 360J

Why:Simplify defibrillationSupport use of device-specific doses

Use of AED’s in Children2005 (New):Recommended use of AED’s in children 1-

8 years old

2000 (Old): Insufficient evidence to recommend for or

against use of AED’s in children under 8 years old

Why: Evidence published since 2000 shows

AED’s safe and effective for use in infants and children

Community/Lay Rescuer AED Programs

2005 (New): CPR/AED use by public safety first responders

recommended to increase SCA survival rates Insufficient evidence to recommend for or against

AED’s in homes

2000 (Old): Key elements of an AED program included:

Physician oversight Training of rescuers Integration with EMS Process of CQI

Community/Lay Rescuer AED Programs cont’d

2005 (Why): The North American PAD trial reinforced the

importance of planned and practiced response.

Even at sites with AED’s in place- the AED’s were deployed for less than half the of the cardiac arrests at those sites indicating the need for frequent CPR

Practice