The new cardiac science"Guidelines" are out! This article is based on information found in the American Heart Association’s Highlights of the 2010 Guidelines for CPR and ECC.
The Guidelines have been developed for resuscitation providers and for AHA instructors. Please reference the American Heart Association website www.americanheart.org, or your instructor materials for additional information. This article is a summary and will address basic life support issues only. Advanced life support issues, as well the addition of new Post-Cardiac Arrest Care and Education will be addressed in future articles.
The 2010 AHA Guidelines for CPR and ECC once again emphasize the need for high-quality CPR, including:
• Compression rate of at least 100/min (a change from approximately 100/min)
• Compression depth of at least 2 inches (5cm) in adults (a change from 1 ½-2 inches)
• Compression depth of 1/3 the diameter of the chest in infants and children (this is deeper for pediatrics than previous versions)
• Allowing for complete chest recoil after each compression
• Minimizing interruptions in chest compressions
• Avoiding excessive ventilation
• Look, listen and feel for breathing has been removed from the all algorithm’s
• Continued emphasis has been placed on high-quality CPR (with chest compressions of adequate rate and depth, allowing complete chest recoil after each compression, minimizing interruptions in compressions, and avoiding excessive ventilation).
There has been no change in the recommendation for compression-to-ventilation ratio of 30:2 for single rescuers of adult, children and infants (excluding newly born infants.) The Guidelines continue to recommend that rescue breaths be given in approximately one (1) second.
Once advanced airways are in place, chest compressions can be continuous or asynchronous (at least a rate of 100/min). Rescue breaths can be provided at about 1 breath every 6-8 seconds (8-10 breaths per minute.) Excessive ventilations should be avoided.
Change From A-B-C to C-A-B
The Guidelines recommend a change in the BLS sequence of steps from A-B-C (airway, breathing, circulation) to C-A-B (circulation, airway, breathing). This fundamental change in CPR sequence will require reeducation of everyone who has ever learned CPR. This change was recommended because, the vast majority of cardiac arrests occur in adults and the highest survival rates from cardiac arrest are reported among patients of all ages who have a witnessed arrest and an initial rhythm of ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT). In these patients, the critical initial elements of BLS are chest compressions and early defibrillation. In the A-B-C- sequence, chest compressions are often delayed while the responder opens the airway to give mouth-to-mouth breaths, retrieves a barrier device, or gathers and assembles ventilation equipment. By changing the sequence to C-A-B, chest compressions will be initiated sooner and the delay in ventilation should be minimal.
Most victims of out-of-hospital cardiac arrest do not receive any bystander CPR. Starting with chest compressions might encourage more rescuers to begin CPR.
Witnessed Arrest vs. Presumed Asphyxial Arrest
If a lone healthcare provider witnesses a victim of sudden collapse, the provider may assume that the victim has had a primary cardiac arrest with a shockable rhythm and should immediately activate the emergency response system, retrieve an AED, and return to the victim to provide CPR and use the AED. But for a presumed victim of asphyxial arrest such as drowning, the priority would be to provide chest compressions with rescue breathing for about 5 cycles (approximately 2 minutes) before activating the emergency response system.
Shock First vs. CPR First
When a rescuer witnesses an out-of-hospital arrest and an AED is available, the rescuer should start chest compressions and use the AED as soon as possible.
Lay Rescuer Summary of Major Changes
1. A simplified universal adult BLS algorithm has been created. (see chart above)
2. Refinements have been made to recommendations for immediate recognition and activation of the emergency response system. This refinement is based on signs of unresponsiveness, as well as initiation of CPR if the victim is unresponsive with no breathing or no normal breathing (i.e., victim is only gasping)
3. There has been a change in the recommended sequence for the lone rescuer to initiate chest compressions before giving rescue breaths (C-A-B rather than A-B-C). The lone rescuer should begin CPR with 30 compressions rather than 2 ventilations to reduce delay to first compression.
4. Compression rate should be at least 100/min (rather than "approximately" 100/min).
5. Compression depth for adults has been changed from the range of 1 ½ -two inches to at least two inches (5cm).
Healthcare Provider BLS Major Changes
1. Because cardiac arrest victims may present with a short period of seizure-like activity or agonal gasps that may confuse potential rescuers, dispatcher should be specifically trained to identify these presentations of cardiac arrest to improve cardiac arrest recognition and prompt provision of CPR.
2. Dispatchers should instruct untrained lay rescuers to provide compressions only CPR for adults with sudden cardiac arrest.
3. Refinements have been made to recommendations for immediate recognition and activation of the emergency response system once the healthcare provider identifies the adult victim who is unresponsive with no breathing or no normal breathing (i.e., no breathing or only gasping). The healthcare provider briefly checks for no breathing or no normal breathing when the provider checks responsiveness. The provider then activates the emergency response system and retrieves the AED (or sends someone to do so). The healthcare provider should not spend more than 10 seconds for a pulse, and if a pulse is not definitely felt within 10 seconds, should begin CPR and use the AED when available.
4. Use of cricoids pressure during ventilations is generally not recommended.
5. Rescue should initiate chest compressions before giving rescue breaths (C-A-B rather than A-B-C). Beginning CPR with 30 compressions rather than 2 ventilations leads to a shorter delay to first compression. Compression rate is modified to at least 100/min from approximately 100/min.
6. Compression depth for adults has been slightly altered to at least 2 inches (about 5cm) from the previous recommended range of about 1 ½ -2 inches (4-5cm).
7. Continued emphasis has been placed on the need to reduce the time between the last compressions and shock delivery and the time between shock delivery and resumption of compressions immediately after shock delivery.
8. There is an increased focus on using a team approach.
Automated External Defibrillators (AED)
The 2010 Guidelines for the use of AEDs has been slightly modified. The use of AEDs in public locations where there is a relatively high likelihood of witnessed cardiac arrest (e.g., airports, casinos, sports facilities). This recommendation identified four components of a successful community lay rescuer AED program to include: (1) a planned and practiced response, typically requiring oversight by a healthcare provider, (2) training of anticipated rescuers in CPR and the use of the AED, (3) a link with the local EMS system, (4) a program of ongoing quality improvement.
AED Use Now Includes Infants
For attempted defibrillation of children 1 to 8 years of age with an AED, the rescuer should use a pediatric dose-attenuator system (pediatric pads) if one is available. If the rescuer provides CPR to a child in cardiac arrest and does not have an AED with pediatric pads, the rescuer should use a standard AED. Although a pediatric system is recommended for both children and infants, if neither is available, an AED without a dose attenuator or pediatric pads may be used.
These changes are designed to simplify training for all level of providers. If there were one message the new science seems to emphasize the need to provide early and high-quality CPR for victims of cardiac arrest.