AHA 2010 GUIDELINES ON CPR

BY :-

SACHIN N SOLANKE MD MEDICINE ASSISTANT PROFESSOR S.R.T.R. MEDICAL COLLEGE AMBAJOGAI

AHA 2010 GUIDELINES ON CPR

CPR was developed in 1950,defibrillation was added in 1958. Changes and refinements in basic life support (BLS) from the 2005 Guidelines include greater emphasis on the early recognition of sudden cardiac arrest (SCA) and beginning excellent CPR immediately. Emphasis is also be placed on encouraging untrained rescuers to perform excellent chest compression-only CPR; early access and use of public access automatic external defibrillators (AEDs) is encouraged. The emergency medical services (EMS) system should be activated as soon as possible once SCA is identified. Patient survival depends primarily upon immediate initiation of excellent CPR and early defibrillation .

C-A-B(Not A-B-C)

BLS
C- CHEST COMPRESSION

A- AIRWAY B- BREATHING

WHY COMPRESSION FIRST?

Ventilations During the initial phase of SCA, when the pulmonary vessels and heart likely contain sufficient oxygenated blood to meet markedly reduced demands, the importance of compressions supersedes ventilations. Consequently, the initiation of excellent chest compressions is the first step to improving oxygen delivery to the tissues .Means during CPR, oxygen delivery to the heart and brain is limited by blood flow rather than by arterial oxygen content This is the rationale behind the compressions-airway-breathing (C-A-B) approach to SCA advocated in the 2010 AHA Guidelines . However, in patients whose cardiac arrest is associated with hypoxia, it is likely that oxygen reserves have been depleted, necessitating the performance of excellent standard CPR with ventilations No look, listen , and feel

Phases of CARDIAC ARREST

There are three phases of cardiac arrest. (A) The electrical phase comprises the first four to five minutes and requires immediate defibrillation. (B) The hemodynamic phase spans approximately minutes four to ten following sudden cardiac arrest (SCA). Patients in the hemodynamic phase benefit from excellent chest compressions to generate adequate cerebral and coronary perfusion and immediate defibrillation. (C) The metabolic phase occurs following approximately ten minutes of pulselessness; few patients who reach this phase survive.

Recognition of cardiac arrest

Rapid recognition of cardiac arrest is the essential first step of successful resuscitation. According to the AHA 2010 Guidelines, the lay rescuer who witnesses a person collapse or comes across an apparently unresponsive person should check the area is safe before approaching the victim and then confirm unresponsiveness by tapping the person on the shoulder and shouting: are you all right? . If the person does not respond, the rescuer calls for help, activates the emergency response system, and initiates excellent chest compressions. After assessing responsiveness, health care providers should quickly check the patients pulse. While doing so, it is reasonable for the healthcare provider to visually assess the patients respirations. It is appropriate to assume the patient is in cardiac arrest if there is no breathing or abnormal breathing (eg, gasping) or if a pulse cannot be readily palpated within 10 seconds. The key point is not to delay CPR.

CHEST COMPRESSION
To perform excellent chest compressions, the rescuer and patient must be in optimal position. This may require adjustment of the beds height, or the use of a step-stool so the rescuer performing chest compressions is appropriately positioned. The patient must lie on a firm surface. This may require a backboard . The rescuer places the heel of one hand in the center of the chest over the lower (caudad) portion of the sternum and the heel of their other hand atop the first. The rescuers own chest should be directly above their hands. This enables the rescuer to use their body weight to compress the patients chest, rather than just the muscles of their arms, which fatigue quickly.

CORRECT WAY OF COMPRESSION

CHEST COMPRESSION COMPRESSION-VENTILATION

Compression-only CPR (CO-CPR)

if a sole lay rescuer is present or multiple lay rescuers are reluctant to perform mouth-to-mouth ventilation, the AHA 2010 Guidelines encourage the performance of CPR using excellent chest compressions alone. The Guidelines further state that lay rescuers should not interrupt excellent chest compressions to palpate for pulses or check for the return of spontaneous circulation, and should continue CPR until an AED is ready to defibrillate, EMS personnel assume care, or the patient wakes up. Note that CO-CPR is not recommended for children or arrest of noncardiac origin (eg, near drowning).

Minimizing interruptions
Interruptions in chest compressions during CPR, no matter how brief, result in unacceptable declines in coronary and cerebral perfusion pressure and worse patient outcomes . Rescuers must ensure that excellent chest compressions are provided with minimal interruption; pulse checks and rhythm analysis without compressions should only be performed at preplanned intervals (every two minutes). Such interruptions should not exceed 10 seconds, except for specific interventions, such as defibrillation. For tracheal intubation, ten seconds hands-off time for the passage of the tube is the only point at which compressions are paused.

When preparing for defibrillation, rescuers should continue performing excellent chest compressions while charging the defibrillator until just before the single shock is delivered, and resume immediately after shock delivery. No more than 3 to 5 seconds should elapse between stopping chest compressions and shock delivery.

Give 2 ventilations after every 30 compressions for patients without an advanced airway Give each ventilation over no more than one second Provide enough tidal volume to see the chest rise Avoid excessive ventilation Give 1 asynchronous ventilation every 8 to 10 seconds (6 to 8 per minute) to patients with an advanced airway in place one asynchronous ventilation 8 to 10 times per minute (every 6 to 8 seconds) in the patient with an advanced airway (eg, supraglottic device, endotracheal tube). Asynchronous implies ventilations need not be coordinated with chest compressions. Ventilations should be delivered in as short a period as possible, not exceeding one second per breath, while avoiding excessive ventilatory force. Only enough tidal volume to confirm initial chest rise should be given. This approach promotes both prompt resumption of compressions and improved cerebral and coronary perfusion. Excessive ventilation, whether by high ventilatory rates or increased volumes, must be avoided. Positive pressure ventilation raises intrathoracic pressure which causes a decrease in venous return, pulmonary perfusion, cardiac output, and cerebral and coronary perfusion pressures [53]. Studies in animal models have found that over-ventilation reduces defibrillation success rates and decreases overall survival .

Proper ventilation for adults

VENTILATION
MOUTH TO MOUTH
MOUTH TO MASK

VENTILATION
BAG MASK WITH TWO RESCUER BAG MASK WITH ONE RESCUER

DEFIBRILLATION
The AHA 2010 Guidelines recommend that all defibrillations for patients in cardiac arrest be delivered at the highest available energy in adults (generally 360 J for a monophasic defibrillator and 200 J for a biphasic defibrillator). This approach reduces interruptions in CPR and is implicitly supported by a study in which out-of-hospital cardiac arrest patients randomly assigned to treatment with escalating energy using a biphasic device showed higher conversion and termination rates for ventricular fibrillation than those assigned to treatment with fixed lower energy Data suggest that the heart does not immediately generate effective cardiac output after defibrillation, and CPR may enhance post-defibrillation perfusion. The 2010 ACLS Guidelines recommend the resumption of CPR immediately after defibrillation without rechecking for a pulse. Interrupt CPR to assess the rhythm and administer additional shocks no more frequently than every two minutes.

AIRWAY MANAGEMENT
clinicians may prefer to ventilate with a supraglottic device while CPR is ongoing, rather than performing tracheal intubation. intubation is performed while excellent chest compressions continue uninterrupted. However, if the operator is unable to intubate during the performance of chest compressions, further attempts should be deferred to the two minute interval (after a complete cycle of CPR) when defibrillation or patient reassessment is performed. This approach minimizes loss of perfusion. Attempts at intubation should last no longer than 10 seconds. The 2010 ACLS Guidelines include the additional recommendations Although evidence is lacking, it is reasonable to provide 100 percent oxygen during CPR. Routine use of cricoid pressure is NOT recommended. Oropharyngeal and nasopharyngeal airways can be useful adjuncts. We encourage their use when performing bag-mask ventilation. Continuous waveform capnography (performed in addition to clinical assessment) is recommended for confirming and monitoring correct endotracheal tube placement. If waveform capnography is not available, a non-waveform CO2 detector or esophageal detector device, in addition to clinical assessment, may be used.

JAW THURST AND HEAD TILT, CHIN LIFT

HIGH QUALITY CPR

Start chest compressions within 10 s of recognition of cardiac arrest. Push hard, push fast:- compression rate at least 100/min, depth at least 2 inches. Allow complete chest recoil after each compression Minimize interruptions in chest compressions to < 10 s Give effective breaths that makes chest rise Avoid excessive ventilation Rotate compressor every 2 min If no advanced airway, 30:2 compression to ventilation ratio Quantitative waveform capnography- PETCO2 < 10 mm Hg, attempt to improve CPR quality Intra arterial pressure- diastolic < 20 mm Hg, attempt to improve CPR quality

UNRESPONSIVE, NO BREATHING OR NO NORMAL BREATHING(GASPING)

ACTIVATE EMERGENCY SYSTEM- GET AED/DEFIB CHECK PULSE(10S)

NO PULSE

DEFINITE PULSE
GIVE 1 BREATH EVERY 5-6 S RECHECK PULSE EVERY 2 MIN

BEGIN CYCLES OF 30 COMPRESSIONS & 2 BREATHS AED/ DEFIB ARRIVES CHECK RHYTHM SHOCKABLE
GIVE 1 SHOCK- RESUME CPR IMMEDIATELY FOR 2 MIN

NOT SHOCKABLE
RESUME CPR IMMEDIATELY FOR 2 MIN, CONT. UNTILL ALS PROVIDERS TAKEOVER OR VICTIM STARTS TO MOVE

BLS

MANAGEMENT OF SYMPTOMATIC BRADYCARDIA & TACHYCARDIA

The goal of therapy for bradycardia or tachycardia is to rapidly identify and treat patients who are hemodynamically unstable. Drugs or, pacing may be used to control unstable or symptomatic bradycardia. Cardioversion or drugs or both may be used to control unstable or symptomatic tachycardia. ACLS providers should closely monitor stable patients pending

BRADYARRHYTHMIA

TACHYARRHYTHMIA

CARDIOVERSION

DRUGS & DOSAGE

USE & TIMING OF DRUGS

current ACLS Guidelines state that the timing of antiarrhythmic use is not specified. But suggested that antiarrhythmic drugs be considered after a second unsuccessful defibrillation attempt in anticipation of a third shock. Amiodarone (300 mg IV with a repeat dose of 150 mg IV as indicated) may be administered in VF or pulseless VT unresponsive to defibrillation, CPR, and epinephrine. Lidocaine (1 to 1.5 mg/kg IV, then 0.5 to 0.75 mg/kg every 5 to 10 minutes) may be used if amiodarone is unavailable. Magnesium sulfate (2 g IV, followed by a maintenance infusion) may be used to treat polymorphic ventricular tachycardia consistent with torsade de pointes. Neither asystole nor PEA responds to defibrillation. Atropine is no longer recommended for the treatment of asystole or PEA. Cardiac pacing is ineffective for cardiac arrest and not recommended in the 2010 ACLS Guidelines. Do not give atropine if there is evidence of a high degree (second degree [Mobitz] type II or third degree) atrioventricular (AV) block [22]. Atropine exerts its antibradycardic effects at the AV node and is unlikely to be effective if a conduction block exists at or below the Bundle of His, or in transplanted hearts, which lack vagal innervation.

WHEN TO STOP CPR?

Victim revive
Trained help arrives Too exhausted to continue Unsafe scene Physician directed (do not resuscitate orders) Cardiac arrest of longer than 30 minutes Initial electrocardiographic rhythm of asystole Prolonged interval between estimated time of arrest and initiation of resuscitation Patient age and severity of comorbid disease Absent brainstem reflexes A very low end tidal CO2 (<10 mmHg) following prolonged resuscitation (>20 minutes) is a sign of absent circulation and an excellent predictor of acute mortality

THANKS