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
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