a14e2010 Guidelines on Cpr (Aha)

8/12/2019 a14e2010 Guidelines on Cpr (Aha)

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AHA 2010 GUIDELINES ON CPR

BY :- SACHIN N SOLANKEMD MEDICINE

ASSISTANT PROFESSOR

S.R.T.R. MEDICAL COLLEGEAMBAJOGAI


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AHA 2010 GUIDELINES ON CPR

CPR was developed in 1950,defibrillation was added in1958.

Changes and refinements in basic life support (BLS) fromthe 2005 Guidelines include greater emphasis on the early

recognition of sudden cardiac arrest (SCA) and beginningexcellent CPR immediately.

Emphasis is also be placed on encouraging untrainedrescuers to perform excellent chest compression-only CPR;early access and use of public access automatic external

defibrillators (AEDs) is encouraged. The emergency medicalservices (EMS) system should be activated as soon aspossible once SCA is identified. Patient survival dependsprimarily upon immediate initiation of excellent CPR andearly defibrillation .


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BLSC-A-B(Not A-B-C)

C- CHEST COMPRESSION

A- AIRWAY

B- BREATHING


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WHY COMPRESSION FIRST?

Ventilations During the initial phase of SCA, when the pulmonary

vessels and heart likely contain sufficient oxygenated blood to meet

markedly reduced demands, the importance of compressions

supersedes ventilations. Consequently, the initiation of excellent chest

compressions is the first step to improving oxygen delivery to thetissues .Means during CPR, oxygen delivery to the heart and brain is

limited by blood flow rather than by arterial oxygen content This is the

rationale behind the compressions-airway-breathing (C-A-B) approach

to SCA advocated in the 2010 AHA Guidelines .

However, in patients whose cardiac arrest is associated with hypoxia, itis likely that oxygen reserves have been depleted, necessitating the

performance of excellent standard CPR with ventilations

No look, listen , and feel


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Phases of CARDIAC ARREST

There are three phases of cardiac arrest.

(A) The electrical phase comprises the first four to fiveminutesand requires immediate defibrillation.

(B) The hemodynamic phase spans approximately

minutes four to ten following sudden cardiac arrest(SCA). Patients in the hemodynamic phase benefit fromexcellent chest compressions to generate adequatecerebral and coronary perfusion and immediatedefibrillation.

(C) The metabolic phase occurs followingapproximately ten minutesof pulselessness; fewpatients who reach this phase survive.


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CHEST COMPRESSION

To perform excellent chest compressions, the rescuer andpatient must be in optimal position. This may requireadjustment of the beds height, or the use of a step-stool sothe rescuer performing chest compressions is appropriatelypositioned. The patient must lie on a firm surface. This mayrequire a backboard .

The rescuer places the heel of one hand in the center ofthe chest over the lower (caudad) portion of the sternumand the heel of their other hand atop the first. Therescuers own chest should be directly above their hands.

This enables the rescuer to use their body weight tocompress the patients chest, rather than just the musclesof their arms, which fatigue quickly.


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CORRECT WAY OF COMPRESSION

CHEST COMPRESSION COMPRESSION-VENTILATION


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Compression-only CPR (CO-CPR)

if a sole lay rescuer is present or multiple lay rescuers are

reluctant to perform mouth-to-mouth ventilation, the AHA

2010 Guidelines encourage the performance of CPR using

excellent chest compressions alone. The Guidelines further

state that lay rescuers should not interrupt excellent chest

compressions to palpate for pulses or check for the return of

spontaneous circulation, and should continue CPR until an

AED is ready to defibrillate, EMS personnel assume care, orthe patient wakes up. Note that CO-CPR is not recommended

for children or arrest of noncardiac origin (eg, near drowning).


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Minimizing interruptions Interruptions in chest compressions during CPR, no matter how brief,

result in unacceptable declines in coronary and cerebral perfusionpressure and worse patient outcomes .

Rescuers must ensure that excellent chest compressions are provided

with minimal interruption; pulse checks and rhythm analysis without

compressions should only be performed at preplanned intervals

(every two minutes). Such interruptions should not exceed 10

seconds, except for specific interventions, such as defibrillation.

For tracheal intubation, ten seconds hands-off time for the passage of

the tube is the only point at which compressions are paused.

When preparing for defibrillation, rescuers should continue

performing excellent chest compressions while charging the

defibrillator until just before the single shock is delivered, and resume

immediately after shock delivery. No more than 3 to 5 seconds should

elapse between stopping chest compressions and shock delivery.


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Proper ventilation for adults Give 2 ventilations after every 30 compressions for patients without an advanced

airway

Give each ventilation over no more than one second

Provide enough tidal volume to see the chest rise Avoid excessive ventilation

Give 1 asynchronous ventilation every 8 to 10 seconds (6 to 8 per minute) to patients

with an advanced airway in place

one asynchronous ventilation 8 to 10 times per minute (every 6 to 8 seconds) in the

patient with an advanced airway (eg, supraglottic device, endotracheal tube).

Asynchronous implies ventilations need not be coordinated with chest compressions.

Ventilations should be delivered in as short a period as possible, not exceeding one

second per breath, while avoiding excessive ventilatory force. Only enough tidal volume

to confirm initial chest rise should be given. This approach promotes both prompt

resumption of compressions and improved cerebral and coronary perfusion.

Excessive ventilation, whether by high ventilatory rates or increased volumes, must be

avoided.

Positive pressure ventilation raises intrathoracic pressure which causes a decrease in

venous return, pulmonary perfusion, cardiac output, and cerebral and coronary

perfusion pressures [53]. Studies in animal models have found that over-ventilation

reduces defibrillation success rates and decreases overall survival .


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VENTILATION

MOUTH TO MOUTH MOUTH TO MASK


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VENTILATION

BAG MASK WITH TWO RESCUER BAG MASK WITH ONE RESCUER


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DEFIBRILLATION

The AHA 2010 Guidelines recommend that all defibrillations forpatients in cardiac arrest be delivered at the highest availableenergy in adults (generally 360 J for a monophasic defibrillator and200 J for a biphasic defibrillator). This approach reducesinterruptions in CPR and is implicitly supported by a study in which

out-of-hospital cardiac arrest patients randomly assigned totreatment with escalating energy using a biphasic device showedhigher conversion and termination rates for ventricular fibrillationthan those assigned to treatment with fixed lower energy

Data suggest that the heart does not immediately generateeffective cardiac output after defibrillation, and CPR may enhance

post-defibrillation perfusion. The 2010 ACLS Guidelines recommendthe resumption of CPR immediately after defibrillation withoutrechecking for a pulse. Interrupt CPR to assess the rhythm andadminister additional shocks no more frequently than every twominutes.


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AIRWAY MANAGEMENT

clinicians may prefer to ventilate with a supraglottic device while CPR is ongoing,

rather than performing tracheal intubation.

intubation is performed while excellent chest compressions continue

uninterrupted. However, if the operator is unable to intubate during the

performance of chest compressions, further attempts should be deferred to the

two minute interval (after a complete cycle of CPR) when defibrillation or patient

reassessment is performed. This approach minimizes loss of perfusion. Attempts atintubation should last no longer than 10 seconds.

The 2010 ACLS Guidelines include the additional recommendations Although

evidence is lacking, it is reasonable to provide 100 percent oxygen during CPR.

Routine use of cricoid pressure is NOT recommended.

Oropharyngeal and nasopharyngeal airways can be useful adjuncts. We encourage

their use when performing bag-mask ventilation.

Continuous waveform capnography (performed in addition to clinical assessment)

is recommended for confirming and monitoring correct endotracheal tube

placement. If waveform capnography is not available, a non-waveform CO2

detector or esophageal detector device, in addition to clinical assessment, may be

used.


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JAW THURST AND HEAD TILT, CHIN LIFT


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HIGH QUALITY CPR Start chest compressions within 10 s of recognition of cardiac

arrest.

Push hard, push fast:- compression rate at least 100/min,depth at least 2 inches.

Allow complete chest recoil after each compression

Minimize interruptions in chest compressions to < 10 s Give effective breaths that makes chest rise

Avoid excessive ventilation

Rotate compressor every 2 min

If no advanced airway, 30:2 compression to ventilation ratio Quantitative waveform capnography- PETCO2 < 10 mm Hg,attempt

to improve CPR quality

Intraarterial pressure- diastolic < 20 mm Hg, attempt toimprove CPR quality


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UNRESPONSIVE, NO BREATHING OR NO NORMAL BREATHING(GASPING)

ACTIVATE EMERGENCY SYSTEM- GET AED/DEFIB

CHECK PULSE(10S)

NO PULSE

BEGIN CYCLES OF 30 COMPRESSIONS & 2 BREATHS

AED/ DEFIB ARRIVES

CHECK RHYTHM

SHOCKABLEGIVE 1 SHOCK- RESUME CPR IMMEDIATELY FOR 2 MIN

NOT SHOCKABLERESUME CPR IMMEDIATELY

FOR 2 MIN, CONT. UNTILL ALS PROVIDERS

TAKEOVER OR VICTIM STARTS TO MOVE

DEFINITE PULSEGIVE 1 BREATH EVERY 5-6 S

RECHECK PULSE EVERY 2 MIN


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BLS


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MANAGEMENT OF SYMPTOMATIC

BRADYCARDIA & TACHYCARDIA


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The goal of therapy forbradycardia or tachycardia is torapidly identify and treat patientswho are hemodynamicallyunstable.

Drugs or, pacing may be used tocontrol unstable or symptomaticbradycardia.

Cardioversion or drugs or both

may be used to control unstable orsymptomatic tachycardia.

ACLS providers should closelymonitor stable patients pending


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BRADYARRHYTHMIA


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TACHYARRHYTHMIA


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DRUGS & DOSAGE

CARDIOVERSION


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USE & TIMING OF DRUGS current ACLS Guidelines state that the timing of antiarrhythmic use is not

specified. But suggested that antiarrhythmic drugs be considered after a

second unsuccessful defibrillation attempt in anticipation of a third shock. Amiodarone (300 mg IV with a repeat dose of 150 mg IV as indicated) may be

administered in VF or pulseless VT unresponsive to defibrillation, CPR, and

epinephrine. Lidocaine (1 to 1.5 mg/kg IV, then 0.5 to 0.75 mg/kg every 5 to

10 minutes) may be used if amiodarone is unavailable. Magnesium sulfate (2 g

IV, followed by a maintenance infusion) may be used to treat polymorphic

ventricular tachycardia consistent with torsade de pointes.

Neither asystole nor PEA responds to defibrillation.

Atropine is no longer recommended for the treatment of asystole or PEA.

Cardiac pacing is ineffective for cardiac arrest and not recommended in the

2010 ACLS Guidelines.

Do not give atropine if there is evidence of a high degree (second degree

[Mobitz] type II or third degree) atrioventricular (AV) block [22]. Atropine

exerts its antibradycardic effects at the AV node and is unlikely to be effective

if a conduction block exists at or below the Bundle of His, or in transplanted

hearts, which lack vagal innervation.


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Victim reviveTrained help arrivesToo exhausted to continueUnsafe scenePhysician directed (do not resuscitate orders)

Cardiac arrest of longer than 30 minutesInitial electrocardiographic rhythm of asystoleProlonged interval between estimated time of arrestand initiation of resuscitationPatient age and severity of comorbid diseaseAbsent brainstem reflexesA very low end tidal CO2 (20 minutes) is a sign ofabsent circulation and an excellent predictor of acutemortality

WHENTO STOP CPR?


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THANKS

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a14e2010 Guidelines on Cpr (Aha)