Highlights of the 2010 AHA :

Guidelines for CPR and ECC

Radityo Prakoso, MD

Why learn CPR ?

Cardiac arrests are more common than you

think, and they can happen to anyone at any
time.

Nearly 383,000 out-of-hospital sudden cardiac

arrests occur annually, and 88 percent of
cardiac arrests occur at home.

85-90% in VF/VT arrest

Greater survival if CPR is immediate, with defib

<5min

Why early CPR and

defibrillation ?

response time is critical; of every minute of delay, survival rates

decrease by 7-10%

Basic Life Support (BLS) :

AHA 2010

Key Changes in the 2010

AHA guidelines

Early recognition of cardiac arrest. unresponsive,no

breathing/normal breathing/gasp.

look, feel, listen has been removed > inconsistent and

time consuming.

CAB rather than ABC. (30:2) shorter delay to first

compression.

No more than 10 seconds to determine pulse

Key Changes in the 2010

AHA guidelines

Hands-only (compression only). easier to

perform for the untrained lay rescuer

High quality CPR. minimize interruption when CPR

performed.

Integrated team of highly trained rescuers.

Building Blocks CPR

CPR Sequence
Change:
From A-B-C to C-A-B
Initiate chest compressions before ventilations

Why?
Goal: To reduce delay to CPR, sequence
begins with skill that everyone can perform
Emphasize primary importance of chest
compressions for professional rescuers
When sudden arrhythmic arrest is present,
oxygen content is initially sufficient, and highquality chest compressions can circulate
oxygenated blood throughout the body.

Elimination of Look, Listen,

and Feel for Breathing
Change:
This action removed from the CPR sequence
After delivery of 30 compressions, lone rescuer opens airway
and delivers 2 breaths.

Why?
Rescuer checks for response and no breathing or no
normal breathing in adult before beginning CPR

Starting CPR with compressions minimizes delay to action

Chest Compression Alone Cardiopulmonary Resuscitation Is Associated

With Better Long-Term Survival Compared with Standard
Cardiopulmonary Resuscitation

Florence duma, et al. Circulation 2013

CPR Starts with Compressions

Many adults with witnessed

arrest have ventricular fibrillation
(VF)/pulseless ventricular
tachycardia (VT), and require
chest compressions
early defibrillation

Chest compressions can be

started immediately (no
equipment needed)

Opening airway, providing

ventilation may significantly
delay other actions
Lindner, et al. Resuscitation 82 (2011) 1508 1513

Quality CPR matters

More than 1 million people suffer a SCA every year with the vast majority dying before
reaching hospital. Research shows that the quality of CPR delivered has a direct impact on a
victims chance of survial

Abella B.S. et al (2005)

bystander CPR increases survival 2-3 times compared to no bystander

CPR.

High Quality CPR

1. Minimize Interruptions: CCF >80%
2. Chest Compression Rate of 100 to 120/min
3. Chest Compression Depth of 50 mm in Adults and at Least
One Third the Anterior-Posterior Dimension of the Chest in
Infants and Children
4. Full Chest Recoil: No Residual Leaning
5. Avoid Excessive Ventilation: Rate <12 Breaths per Minute,
Minimal Chest Rise

1. Minimize Interruption

for adequate tissue oxygenation, maximize the amount of

time chest compressions generate blood flow. > Target
CCF >80%

2. Chest Compression Rate

Change :

Relationship between chest compression rates

and the probability of return of spontaneous
circulation (ROSC).

- Compression rate at least 100

per minute
(old) 2005 recommendation:
Compression rate about 100/min

Why?
Absolute number of compressions
delivered/minute has been linked
with survival.
As chest compression rates fall, a
significant drop-off in ROSC occurs,
and higher rates may reduce
coronary blood flow
Ahamed H, et al. Circulation 2012; 125: 3004-3012

3. Adult Chest Compression Depth

Compressions generate critical blood flow and
oxygen and energy delivery to the heart and brain

Change:
Compress at least 2 inches (>50 mm)
2005 recommendation was 112 to 2 inches.

Why?
Compressions of at least 2 inches are
more effective than those of 112 inches.

Rescuers often do not push hard

enough.

Confusion may result when a range

of depths is recommended

Ian G, et al. Crit Care Med. 2012 Apr; 40(4): 11921198.

4. Full Chest Recoil

Leaning is known to decrease

the blood flow throughout the
heart and can decrease
venous return and cardiac
output

leaning increases right atrial

pressure and decreases
cerebral and coronary
perfusion pressure, cardiac
index, and left ventricular
myocardial flow

5. Avoid Excessive Ventilation

Providing sufficient oxygen to the

blood without impeding perfusion,
recommends a ventilation rate of <12
breaths

Excessive ventilation reduces CPP

and cerebral perfusion

Over ventilation increases air in

stomach

Long breaths interrupt compressions

Team
Resuscitation
Change:
Increased focus on using a team approach during
resuscitations

Why:
Many CPR interventions performed simultaneously
Collaborative work minimizes interruption in
compressions
Clear communication minimizes errors

Key Challenges to
improve CPR Quality

Circulation
Volume 122(18 suppl 3):S676-S684
November 2, 2010

Simplified adult BLS algorithm

Berg R et al. Circulation 2010;122:S685-S705

Copyright American Heart Association

BLS healthcare provider algorithm

Berg R et al. Circulation 2010;122:S685-S705

Copyright American Heart Association

Advanced Cardiovascular Life

Support (ACLS) : AHA 2010

Major Changes in AHA 2010

use of quantitative waveform capnography for confirmation and

monitoring ETT placement (Class 1 recommendation)

Traditional cardiac arrest algorithm simplified and alternative

conceptual design (both emphasize importance of high-quality
CPR.)

Increased emphasis on continuous waveform capnography to

verify endotracheal tube placement

optimize CPR quality and detect ROSC.

cricoid pressure during airway management is no longer

recommended

Major Changes in AHA 2010

atropine is no longer recommended for PEA/asystole

adenosine for the diagnosis and treatment stable undifferentiatied

wide-complex tachycardia (regular, monomorphic)

symptomatic/unstable bradycardia, chronotropic IV lnfusion as

effective as external pacing when atropine is ineffective.

systematic post cardiac arrest care after ROSC should continue in

critical care unit with expert multidisciplinary management and
assesment (neuorologic and phsyiologic)

New AHA Adult Chain of Survival

New 5th link post-cardiac arrest care

Links in the new adult Chain of Survival:
Immediate recognition and activation of emergency
response system
Early CPR, w/emphasis on chest compressions

Rapid defibrillation

Effective advanced life support

Integrated post cardiac arrest care

Simplified ACLS Algorithm and New

Algorithm

Change :
simplified and streamlined to emphasize the
importance of high quality CPR
ACLS actions should be organized around
uninterrupted periods of CPR

Why ?
ACLS interventions build on the BLS foundation of
high quality CPR

Simplified ACLS Algorithm and New

Algorithm

ACLS: Waveform Capnography

Change:
Quantitative waveform capnography is most reliable method to confirm
and monitor correct ET tube placement (Class I, LOE A).
Old : After intubation, exhaled carbon dioxide is detected,
confirming tracheal tube placement.

Why:
Unacceptably high incidence of unrecognized
ET tube misplacement or displacement.

Capnography has high sensitivity and specificity to identify correct

endotracheal tube placement in cardiac arrest.

ACLS: Waveform Capnography

Cricoid Pressure
Change:
Routine use of cricoid pressure during
CPR is generally NOT recommended.

Why:
Cricoid pressure can interfere with
ventilation and advanced airway
placement.

Not proven to prevent aspiration or

gastric insufflation during cardiac arrest.

Post-Cardiac Arrest Care

Change:
New 5th link in the chain of survival

Why:
Emphasize importance of comprehensive multidisciplinary care
through hospital discharge and beyond

Includes:
Optimizing vital organ perfusion
Titration of FiO2 to maintain O2 sat 94% and < 100%
Transport to comprehensive post-arrest system of care
Emergent coronary reperfusion for STEMI or high suspicion of AMI
Temperature control to optimize neuorologic recovery
Anticipation, treatment, and prevention of multiple organ dysfunction

Adult Cardiac Arrest

Algorythm

neumar, et al. Circulationn. 2010

Summary

ACLS does not end when a patient achieves ROSC.

There are guidelines for post cardiac arrest management

and include new early post cardiac arrest treatment
algorithm.

Many resuscitation systems and communities have

documented improved survival from cardiac arrest.

Too few victims of cardiac arrest receive bystander CPR.

Summary

CPR quality must be high.

Victims require excellent postcardiac arrest

care by organized, integrated teams.

Education and frequent refresher training key to

improving resuscitation performance.

We must rededicate ourselves to improving the

frequency of bystander CPR, the quality of all
CPR and the quality of postcardiac arrest care.

THANK YOU