SUMMARY OF MAJOR CHANGES 2010 AHA GUIDELINES FOR CPR & ECC The following is a summary of the key issues and changes in the AHA 2010 Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care (ECC). These guidelines are based on an evidence-based evaluation process which involved hundreds of international resuscitation scientists & experts who evaluated, discussed & debated thousands of peer-reviewed publications. AHA ECC ADULT CHAIN OF SURVIVAL A new link, integrated post-cardiac arrest care, has been added to the AHA ECC Adult Chain of Survival BLS if the patient is unresponsive with no breathing or no normal breathing ( agonal resps or gasping), activate the emergency response system, retrieve an AED (or send someone to do so) and start CPR immediately Look, listen & feel for breathing has been eliminated. After delivering 30 compressions, the victim s airway should be opened & 2 breaths administered
The sequence of steps in the BLS algorithm have changed to C-A-B (Chest compressions-airway-breathing), rather than A-B-C o The vast majority of adult cardiac arrests occur due to ventricular fibrillation or ventricular tachycardia. In these patients, chest compressions & early defibrillation are of the utmost importance. By changing the sequence to C-A-B, chest compressions will be initiated sooner & the delay in ventilation should be minimal. The need for high-quality CPR is again being emphasized including: o A compression rate of at least 100/minute (changed from approximately 100/minute) o A compression depth of at least 2 inches in adults (changed from 1 ½ - 2 ) o Allow for complete chest recoil after each compression o Minimize interruptions in chest compressions o Rotate compressors every 2 minutes to maintain efficacy o Avoid excessive ventilation Compression to ventilation ratio of 30:2 remains with each breath being given over 1 second until an advanced airway is placed Give 1 breath every 6 8 seconds without interrupting compressions once an advanced airway has been placed The use of cricoid pressure is now discouraged 2
BLS COMPONENTS FOR HEALTH CARE PROVIDERS COMPONENT Recognition Pulse Check CPR Sequence Compression Rate Compression Depth Chest Wall Recoil Compression Interruptions Airway Compression to Ventilation Ratio (until advanced airway placed) Compression to Ventilation Ratio (once advanced airway is placed) Defibrillation RECOMMENDATIONS No breathing or no normal breathing Palpate carotid pulse for no more than 10 seconds C - A - B At least 100 per minute At least 2 inches o Allow complete recoil o Change compressors every 2 minutes o Minimize interruptions as much as possible o Interruptions should be less than 10 seconds o Head tilt-chin lift or jaw thrust o Bag-valve-mask with oral airway o Increased emphasis on supra-glottic devices o Decreased emphasis on immediate placement of an ETT 30 : 2 o Continuous chest compressions of at least 100 per minute o 1 breath every 6-8 seconds with visible chest rise o Attach & use AED as soon as available o Minimize interruptions in chest compressions before & after shock o Resume CPR beginning with compressions immediately after each shock. KEY CHANGES FOR ACLS The ACLS Cardiac Arrest Algorithm has been simplified and streamlined to emphasize the importance of high quality CPR and that ACLS actions should be organized around uninterrupted periods of CPR. The ACLS Algorithms now focus on interventions that have the greatest impact on outcome. The main emphasis is now on high quality CPR, early defibrillation & reversal of the possible underlying cause. Vascular access, drug delivery & advanced airway placement, although still recommended, should not cause significant interruptions in chest compressions and should not delay shocks. 3
CIRCULAR ACLS ALGORITHM o Quantitative waveform capnography is now recommended (in addition to clinical assessments such as auscultation) for confirmation of ETT placement, monitoring of CPR quality and detecting ROSC (return of spontaneous circulation) based on end-tidal carbon dioxide (ETCO2) values. o Continuous waveform capnography is the most reliable method of confirming & monitoring correct ETT placement o Capnography can also serve as a physiologic monitor of the effectiveness of chest compressions & to detect ROSC Ineffective chest compressions are associated with a low ETCO2 Falling cardiac output or rearrest after ROSC will cause a decrease in ETCO2 ROSC may cause an abrupt increase in ETCO2 o If waveform capnography is not available, a nonwaveform qualitative ETCO2 detector (ie. Easy Cap ) may be used in conjunction with clinical assessment 4
CAPNOGRAPHY TO MONITOR EFFECTIVENESS OF RESUSCITATION This capnography tracing displays the ETCO2 in mm Hg over time. The patient is intubated & receiving CPR. The ETCO2 is less than 12.5 during the first minute, indicating very low blood flow. The ETCO2 increase to between 12.5 and 25 mm Hg during the second & third minutes, consistent with the increase in blood flow with ongoing resuscitation. ROSC occurs during the 4 th minute & is recognized by the abrupt increase in ETCO2 to over 40 mm Hg. CHANGES TO ELECTRICAL THERAPIES AEDS: o Increased emphasis on the integration of AED use in public places o AEDs may be considered for use in the hospital setting as a way to facilitate early defibrillation (a goal of shock delivery 3 minutes from collapse), especially in areas where staff have limited or no recognition skills or defibrillators are used infrequently. Healthcare providers who treat cardiac arrest in hospitals or other facilities with on-site AEDs or defibrillators should provide immediate CPR and use the AED/defibrillator as soon as it is available CARDIOVERSION: o the initial energy level for atrial fibrillation is now 120 200 joules biphasic or 360 joules monophasic o the initial energy level for unstable monomorphic VT is 100 joules biphasic o the initial energy level for atrial flutter & other SVTs is 50 100 joules biphasic o to keep it simple, start at 100 joules biphasic for all rhythms other than a-fib o increase energy levels in a step-like fashion for subsequent attempts 5
MEDICATION CHANGES Atropine is no longer recommended for routine use in the management of Asystole or PEA & has been removed from the ACLS Cardiac Arrest Algorithm o Atropine can still be considered for use in symptomatic sinus bradycardia Adenosine may now be considered for use in the initial diagnosis & treatment of stable, regular, monomorphic, wide-complex tachycardia which is regular o Adenosine should not be used for irregular wide-complex tachycardias!!! Chronotropic drug infusions (ie. Epinephrine infusion and/or Dopamine infusion) may now be considered for patients with unstable bradycardia. These infusions are now felt to be an equally effective alternative to transcutaneous pacing Amiodarone continues to be the antiarrhythmic of choice for refractory VF or VT Magnesium Sulfate is now only recommended for torsades des pointes associated with known prolonged QT interval ORGANIZED POST-CARDIAC ARREST CARE Post-Cardiac Arrest Care is a new link in the AHA ECC Adult Chain of Survival & the 2010 AHA Guidelines for CPR & ECC. Organized post-cardiac arrest care with emphasis on protocols for optimizing cardiovascular & neurological care, including therapeutic hypothermia, can improve survival to hospital discharge among victims who achieve ROSC after cardiac arrest. Treatment should include: Cardiopulmonary & neurological support Therapeutic hypothermia when indicated o Cooling should be initiated as soon as possible for adults who have ROSC after cardiac arrest but lack meaningful response to verbal commands or a GCS less than 10 6
o Intubation, mechanical ventilation & neuromuscular blockade in conjunction with sedation & analgesia are essential o Goal is a core temperature between 30 32 C for 12 24 hours o Initiate cooling with ice packs to the neck, axial & groin. Remove once target temperature is reached o Administer 30 ml/kg ice cold NS over 30 60 minutes if tolerated o Apply surface cooling blanket if available o Elevate head of bed 30 o Monitor vital signs q1h including HR, BP, RR, Temp, MAP, CVP and SpO2 o Please Note: The therapeutic hypothermia protocol is very long & complicated. The above are just a few of the highlights. When implementing any procedure please be sure to follow your institution s policy! Glucose control when indicated o Blood glucose values > 10 mmol/l should be treated & hypoglycemia avoided Percutaneous Coronary Interventions (PCI) as required o May be performed concurrently with therapeutic hypothermia o Immediate angiography & PCI should be considered whenever possible for patients with OHCA & ROSC even in the absence of ST segment elevation on the ECG or prior clinical findings such as chest pain Frequent or preferably continuous EEG monitoring to detect seizure activity TAPERING OXYGEN CONCENTRATION AFTER ROSC Once ROSC has been achieved, arterial oxyhemoglobin saturation should be monitored wherever possible. If appropriate equipment is available, titrate oxygen administration to the minimum concentration needed to maintain arterial oxyhemoglobin saturation 94%. In this way hyperoxia is avoided while ensuring adequate oxygen delivery. CHANGES IN ACS MANAGEMENT An organized approach to STEMI care is now encouraged o Involves integration of community systems, EMS protocols, healthcare professionals and available hospital resources Emphasis has now been placed on out-of-hospital 12 lead ECGs with transmission or interpretation by EMS providers & advanced notification of receiving facility o Reduces time to reperfusion with fibrinolytic therapy 7
o Can significantly reduce time to primary PCI by triaging directly to a PCI capable facility Supplementary oxygen is no longer routinely recommended for ACS patients without evidence of respiratory distress if the O2 sat is 94%. However, if the patient is dyspneic, hypoxic or has signs of heart failure, oxygen should be provided & titrated to maintain an O2 sat 94% Morphine should be used with caution in patients with unstable angina/non- STEMI since it has been associated with an increased mortality rate. Morphine is however still indicated for STEMI patients with chest pain unresponsive to nitrates. 8