2005 AHA Guideline Changes BLS for Healthcare Providers

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2005 AHA Guideline ChangesBLS for Healthcare
Providers
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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

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What Have We Learned About CPR?

• 330,000 die annually from coronary heart disease
  CDC
• 60 from SCA _at_ home or en route
• 85-90 in VF/VT arrest
• 2-3 x greater survival if CPR is immediate, with
  defib lt5 min.
• EMS relies on trained, willing, equipped public

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Less than 1/3 get bystander CPREven pros dont
do good CPR!

• Too slow
• Too shallow
• No CPR x 24-49 of the arrest!

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Most significant changes 2005

• ITS ALL ABOUT BLOOD FLOW!
• Emphasis on effective CPR
• Fast deep 50/50 minimal interruption
• Single compression-to-ventilation ratio
• 302 single rescuer adult, child, infant,
  excluding newborns

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Most significant changes (cont.)

• Each shock from an AED should be followed by 2
  minutes of CPR (5 cycles of 302) 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.

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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

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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

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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)

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Chest Compressions

• 2005 (New)
• Push hard, fast, rate of 100 per minute
• Allow full chest recoil after each compression
• Minimize interruptions (no more than 10 seconds
  at a time) except for specific interventions
  (advanced airway/AED)

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Chest Compressions contd

• 2000 (Old)
• Less emphasis was given to need for adequate
  depth, complete chest recoil, and minimizing
  interruptions

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Chest Compressions contd

• Why
• If chest not allowed to recoil
• less venous return to heart
• reduced filling of heart
• Decreased cardiac output for subsequent chest
  compressions
• When chest compressions are interrupted, blood
  flow stops and coronary artery perfusion pressure
  falls

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Chest Compressions contd

• Why
• Study of CPR performed by healthcare providers
  found that
• ½ of chest compressions too shallow
• No compressions provided during 24 to 49 of CPR
  time

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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)

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Rescue Breathing without Compressions

• 2005 (New)
• 10-12 breaths per minute (adults) 1 every 5-6
  seconds
• 12-20 breaths per minute for infant or child 1
  every 3-5 seconds
• 2000 (Old)
• 10-12 breaths for adults
• 20 breaths for infant or child

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Rescue Breathing without Compressions contd

• 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

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Rescue Breaths with Compressions

• 2005 (New)
• Each rescue breath should be given over 1 second
  and produce visible chest rise
• Avoid breaths that are too large or too forceful
• Manikins configured so that visible chest rise
  occurs at 500-600ml
• 2000 (Old)
• Rescue breaths over 1-2 seconds
• Recommended tidal volume for adult rescue breaths
  was 700ml-1000ml

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Rescue Breaths with Compressions contd

• 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

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Rescue Breaths with Compressions contd

• 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

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Rescue Breaths with Compressions contd

• Why
• Hyperventilation leads to
• Increased positive pressure in the chest
• Decreased venous return to the heart
• Limited refilling of heart
• Decreased cardiac output during subsequent
  compressions
• Gastric distention/vomiting

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2 Rescuer CPR with Advanced Airway

• 2005 (New)
• No pause for ventilation when there is an
  advanced airway in place
• 8-10 breaths per minute

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2 Rescuer CPR with Advanced Airway contd

• 2000 (Old)
• Recommended asynchronous compressions and
  ventilations
• Ventilation rate of 12-15 per minute
• Rescuers taught to re-check for signs of
  circulation every few minutes

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2 Rescuer CPR with Advanced Airway contd

• Why
• Ventilations can be delivered during compressions
• Avoid excessive number of breaths
• During CPR, blood flow to lungs decreased, so
  lower than normal respiratory rate will maintain
  adequate oxygenation

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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

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Airway/Trauma Victims contd

• 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

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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

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Adequate vs. Presence or Absence of Breathing
contd

• 2000 (Old)
• Healthcare provider checked for adequate
  breathing for victims of all ages
• Why
• Children may demonstrate breathing patterns
  (rapid, grunting) which are adequate but not
  normal
• Assessment for adequate breathing is more
  consistent with advanced provider skill

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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

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Infant/Child Give 2 Effective Breaths contd

• Why
• Most common mechanism of cardiac arrest in
  infants and children is asphyxial
• Rescuer must be able to provide effective breaths
  

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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

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Lone Healthcare Provider contd

• 2000 (Old) Tailoring response to likely cause of
  arrest was not emphasized in training
• Why
• Sudden collapse-likely cardiac and early CPR and
  defibrillation needed
• Victims of hypoxic arrest need immediate CPR

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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

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Child BLS contd

• 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

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Symptomatic BradycardiaInfants/Children

• 2005 (New)
• Chest compressions indicated if HR lt60 and signs
  of poor perfusion, despite adequate ventilation
• 2000 (Old)
• Same recommendation in 2000 guidelines but it was
  not incorporated into the BLS training

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Symptomatic BradycardiaInfants/Children contd

• 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

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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

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Infant Chest Compressions

• 2005 (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

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Compression to Ventilation Ratios Infants/Children

• 2005 (New)
• Lone rescuerCompression to ventilation ratio
  302 for infants, children and adults for
• 2 Rescuer CPR 152 ratio for infants and
  children
• 2000 (Old)
• 152 adults 51 infants/children

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Compression to Ventilation Ratios
Infants/Children contd

• Why
• Simplify training
• Reduce interruptions in chest compressions
• 152 ratio for 2 rescuer CPR for infants/children
  will provide additional ventilations

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Foreign Body Airway Obstruction

• 2005 (New)
• Airway obstructions classified as mild or severe
• Rescuers should act only if signs of severe
  obstruction present
• poor air exchange
• Increased respiratory distress
• Silent cough
• Cyanosis
• Inability to speak or breath

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Foreign Body Airway Obstruction contd

• 2005 (New) contd
• If victim becomes unresponsive
• ACTIVATE 9-1-1 and begin CPR
• When airway opened during CPR, look in mouth and
  remove object if seen
• No blind finger sweeps

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Foreign Body Airway Obstruction contd

• 2000 (Old)
• Rescuers taught to recognize
• Partial obstruction with good air exchange
• Partial obstruction with poor air exchange
• Complete airway obstruction
• Rescuers taught to ask 2 questions
• Are you choking?
• Can you speak?
• Sequence for unresponsive choking victim was a
  complicated sequence/included abdominal thrusts

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Foreign Body Airway Obstruction contd

• Why
• Simplification
• Compressions during CPR may increase
  intrathoracic pressure more than abdominal
  thrusts
• Blind finger sweeps may injure victims
  mouth/throat or rescuers finger

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Shock /Immediate CPR

• 2005 (New)
• Delivery of single shock for VF and pulseless VT
  followed by immediate CPR
• Perform 2 minutes of CPR before checking for
  signs of circulation

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Shock /Immediate CPR contd

• 2000 (Old)
• 3 stacked shocks recommended
• Why
• 3 shocks were based on use of monophasic
  waveforms
• New biphasic defibrillators have a higher
  first-shock success rate
• 3-shock sequence can result in delays up to 37
  seconds or longer from delivery of shock and
  delivery of first post-shock compression

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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

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Biphasic Defibrillation Dose

• 2005 (New)
• Initial shock for adults150-200J for biphasic
  truncated exponential waveform
• 120J for rectilinear biphasic waveform
• The 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

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Biphasic Defibrillation Dose contd

• 2000 (Old)
• 200J, 200-300J, 360J
• Why
• Simplify defibrillation
• Support use of device-specific doses

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Use of AEDs in Children

• 2005 (New)
• Recommended use of AEDs in children 1-8 years
  old
• 2000 (Old)
• Insufficient evidence to recommend for or
  against use of AEDs in children under 8 years
  old
• Why
• Evidence published since 2000 shows AEDs safe
  and effective for use in infants and children

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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
  AEDs in homes
• 2000 (Old)
• Key elements of an AED program included
• Physician oversight
• Training of rescuers
• Integration with EMS
• Process of CQI

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Community/Lay Rescuer AED Programs contd

• 2005 (Why)
• The North American PAD trial reinforced the
  importance of planned and practiced response.
• Even at sites with AEDs in place- the AEDs
  were deployed for less than half the of the
  cardiac arrests at those sites indicating the
  need for frequent CPR

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Practice