New York State Protocols

Update 2006

Including AHA changes

American Heart Association

Approximately 330,000 prehospital and Emergency Department deaths/year in US are from cardiac arrest

Survival is 6.4% or less

Changes in AHA guidelines are based on research

Major Changes for Everyone

Emphasis on effective chest compressions

Universal compression:ventilation ratio for lone rescuer

1 Second breaths during CPR

1 Shock, then immediate CPR

Effective Chest Compressions

Change:Push hard and push fast

Why:Need adequate rate and depth in order to produce blood flow and

perfuse vital organs

Change:Equal compression/relaxation times

Why:Need full recoil of chest in order to have better blood flow

Change - not emphasized

Effective Chest Compressions, continued

Change:Limit Interruptions to chest compressions

Why:Blood flow stops when CPR is interrupted, more compressions in

a row provides better blood flow

Change –never limited

Universal Compression:Ventilation Ratio

Change:

30:2 for lone rescuer, infants through adults (not newborns)

Why:

Simplify information, longer series of uninterrupted compressions

Changed from - 15:2

1 Second Breaths

Change:

Give the recommended number of breaths, with each breath given over 1 second

Why:

Lungs require less oxygen during CPR due to decreased blood flow and it is important to reduce interruptions to compressions

Changed from - breaths over 1-2 seconds, the more the better

1 Second Breaths, continued

Change:

Avoid delivering too many breaths or breaths that are too large or too forceful

Why:

Too much volume in the chest cavity decreases blood return to the heart. Too forceful a breath can cause gastric distention

and all it implies.

Changed from - belief that more oxygen was better

1 Shock, Immediate CPR

Change:

Deliver 1 shock, followed by the compression phase of CPR, continue 5 cycles

Why:

There is almost a 40 second delay in analyzing the rhythm, delaying blood flow to vital organs

V-fib is almost always eliminated in first shock so stacked shocks aren’t usually necessary.

After shocking, it takes a few moments for a normal heart rhythm to return and more time for optimal blood flow, CPR can

help increase the blood flow sooner

Changed from - stacked shocks

Major Changes for EMS

Definition of “Child” Tailor sequence for most likely cause Opening the Airway, Trauma Victim Check for “adequate” breathing Try a couple of times to get chest rise Excessive ventilation should not be performed

Major Changes for EMS, continued

Emphasis on CPR children with HR <60bpm Compressions at adequate rate and depth Hand placement change for pediatrics Compression:Ventilation ratio changes With advanced airway no pause for breaths When 2 or more providers, rotate compressor role every 2

minutes

Definition of “Child”

Change:

1 year to onset of puberty

Why:

Difficult to pick one anatomical or physiological

characteristic that changes “child” to “adult”

Changed from - 1-8 years

Tailor Sequence to Cause

Change

Adult – phone first, get AED, provide CPR

Infant/Child – CPR for 2 min, phone 911, AED when available

Any age- Hypoxic event, CPR for 2 min, phone 911, AED when available

Why:

Sudden collapse requires AED, Hypoxic event requires immediate CPR before activating 911

Change –not emphasized

Opening the Airway, Trauma Victim

Change:

Head tilt – chin lift unless c-spine injury is suspected

Jaw thrust - if c-spine injury suspected, unless maneuver doesn’t work, then head tilt –chin lift

Why:

Airway is a priority

Changed from - Jaw thrust only

Check for “Adequate” breathing

Change:Adults -Check for “adequate” vs “normal” breathing, give 2 breathsInfant/Child – check for presence/absence of breathing, give 2 breaths if not breathing

Why:No need to wait for apnea in adultsDifficult to assess “adequate” but not “normal” breathing in pediatrics

Changed from - check for adequate breathing for all victims

Chest Rise

Change:Try a “couple of times” to get adequate chest rise

Why:Asphyxia most common cause of cardiac arrest, need to try a “couple of times” to provide effective breaths

Changed from - maneuver head to get optimal airway opening

Excessive Ventilation

Change:

Give breath over 1 second, with just enough force to get chest rise

Why:

Less ventilation than normal needed during CPR

During CPR blood flow to lungs is 25% of normal, requiring less oxygen

Hyperventilation decreases blood return to heart and can cause gastric distention

Changed from - 1-2 seconds, large breaths

CPR for peds HR<60bpm

Change:

Despite adequate ventilatory support, HR remains<60bpm, if so, begin CPR

Why:

Bradycardia is a common terminal rhythm in children

Change –not emphasized

Adequate Rate and Depth

Change:Push Hard, Push Fast, allow recoilLimit interruptions to 10 seconds

Why:More effective chest compressionsIncreased cardiac outputBetter blood flow

Changed from -no emphasis on recoil

Hand Placement

Change:Children – heel of 1 or two hands

Why:Depending on child’s size, better compressions were found to be

done with 2 hands

Change:Infants: - 2 thumb-encircling hands technique

Why:Produces higher coronary artery perfusion pressureBetter depth and force of compressionGenerates higher systolic and diastolic pressures

Changed from -1 hand in children and 2 fingers in infants

Compression:Ventilation Ratio

Change:1 rescuer – 30:22 rescuer – 15:2

Why:Simplify trainingReduce interruptions

Changed from - 5:1

Advanced Airway

Change:

Once an advanced airway ( ET Tube, LMA, Combitube) is in place, continuous compressions at a rate of 100/minute

Why:

No need to pause for breath, provides uninterrupted chest compressions

Changed from - asynchronous compressions

Rotate Compressor Role

Change:

Rotate compressor role every 2-3 cycles

Why:

At the new rate compressors will tire more easily and may provide inadequate compressions

Change: not emphasized

Foreign Body Obstruction

Change:Intervention only applied to those with severe obstruction – (poor

air exchange, increased breathing difficulty, silent cough, cyanosis, inability to speak or breathe)

Why: not everyone requires intervention

Change:CPR instead of abdominal thrusts

Why:Previous system more complicated, CPR just as effective as abdominal thrusts

Changed from - intervention if even mild symptoms, abdominal thrusts and back blows

Foreign Body Obstruction, continued

Change:In an unresponsive person, every attempt to deliver breaths should start with looking in the mouth and removing object if seen. Blind finger sweeps should not be performed

Why:Blind finger sweeps can result in damage to mouth or throat or to

rescuer’s finger, and there is no evidence of effectiveness

Changed from - blind finger sweeps in adults

What hasn’t changed?

EMS Providers:

BLSChecking for responsePulse checkRescue breathing without chest compressionsHand placement for adult chest compressions Compression rateCompression depth Ages used for infant BLS recommendations

DefibrillationInitial dose for infants and children

NYS ProtocolsAdult Obstructed Airway

ALWAYS: Request ALS, do not delay transport, keep patient warm

If pt is conscious and can breathe, cough or speak:Do not interfere. Encourage coughing.

If unable to dislodge obstruction with coughing:Admin high flow O2, transport in sitting position,

If pt is conscious with signs of severe airway obstruction:Perform obstructed airway maneuvers

If airway obstruction persists or pt becomes unconscious:Begin CPR, transport

If airway obstruction is cleared and pt resumes breathing:Admin High flow O2, transport

Changed from -continue obstructed airway maneuvers to CPR

NYS ProtocolsPediatric Obstructed Airway

ALWAYS: Request ALS, do not delay transport, keep patient warm, don’t agitate child, transport

If pt is conscious and can breathe, cough or speak:Do not interfere, position of comfort, encourage

coughing. If conscious but unable to breath, cough, speak or cry:

Perform obstructed airway maneuvers If pt is unconscious or becomes unconscious & is not breathing:

Establish BLS airway, remove visible foreign body, CPR, If airway obstruction is cleared and/or establishment of chest rise:

Assess respiratory status, O2, assist respirations prn

Changed from - continue obstructed airway maneuvers to CPR

NYS ProtocolsAdult Respiratory Arrest/Failure

ALWAYS: Request ALS, do not delay transport, keep patient warm

Inadequate ventilatory status:OPA (or NPA) High Flow O2 with BVM Rate 10-12/min, each over 1 secondTidal Volume adequate to make chest rise

Changed from - without O2 700-1000ml over 2 seconds, or with O2 400-600ml over 1-2 seconds

NYS ProtocolsPediatric Respiratory Arrest/Failure

ALWAYS: Request ALS, do not delay transport, keep patient warm

Inadequate ventilatory status:

OPA (or NPA) High Flow O2 with BVM

Rate 12-20/min, each over 1 second

Tidal Volume adequate to make chest rise

Changed from - without O2 450-500ml over 2 seconds, or with O2 400-600ml over 1-2 seconds

NYS ProtocolsAdult & Pediatric Cardiac Arrest

ALWAYS: DNR?, Request ALS, do not delay transport

If apneic and pulseless: If unwitnessed or EMS arrival ≥ 4 minutes since arrest:

CPR (5 cycles/2 min) prior to AED. Compressions 15:2 (2 person) If witnessed or EMS arrival < 4 minutes since arrest:

AED first, then CPR prn, Compressions 15:2 (2 person) If secured advanced airway:

Respiratory rate 8-10/minute, no pause in compressions If one rescuer CPR compressions at 30:2

Changed from - old compression ratio, AED first always

NYS ProtocolsAdult & Pediatric Cardiac Arrest, continued

AEDMonophasic- All shocks at 360jBiphasic – All shocks at 120-200jPediatric – under age 8 use pediatric pads

After all shocks CPR for 5 cycles/2min without checking pulse, rhythm check and/or defib.

Pulse check after 5 cycles/2min or if pt appears to no longer be in cardiac arrest

Max of 3 shocks on scene before transport

Changed from - stacked shocks and joule settings, longer scene time

NYS ProtocolsEmergency Childbirth, Resuscitation and Stabilization of the Newborn

ALWAYS: Request ALS, do not delay transport

If newborn RR is absent or depressed (<30bpm):

ventilate with high flow O2 at 40-60bpm

If newborn’s HR <60 or does not increase above 60 bpm

after 30 seconds of assisted ventilations:

Add chest compressions

at rate of 100/min and

ratio of 30:2 for 1 rescuer, 15:2 for 2 rescuers

Changed from - RR 30-60, HR – does not increase