1. 2005 AHA Guideline Changes BLS for Healthcare Providers

2. 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%

3. What Have We Learned About CPR?
330,000 die annually from coronary heart disease CDC
60% from home or en route
85-90% in VF/VT arrest
2-3 x greater survival if CPR is immediate, with defib <5 min.
EMS relies on trained, willing, equipped public

4. Less than 1/3 get bystander CPR Even pros don’t do good CPR!
Too slow
Too shallow
No CPR x 24-49% of the arrest!

5. Most significant changes 2005
IT’S ALL ABOUT BLOOD FLOW!
Emphasis on effective CPR
Fast; deep; 50/50; minimal interruption
Single compression-to-ventilation ratio
30:2 single rescuer adult, child, infant, excluding newborns

6. 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.

7. 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”

8. 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

9. 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)

10. 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)

11. Chest Compressions cont’d
2000 (Old):
Less emphasis was given to need for adequate depth, complete chest recoil, and minimizing interruptions

12. Chest Compressions cont’d
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

13. Chest Compressions cont’d
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

14. 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)

15. 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

16. 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

17. 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 ml
2000 (Old):
Rescue breaths over 1-2 seconds
Recommended tidal volume for adult rescue breaths was 700ml-1000ml

18. 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

19. 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

20. Rescue Breaths with Compressions cont’d
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

21. 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

22. 2 Rescuer CPR with Advanced Airway cont’d
2000 (Old):
Recommended “asynchronous” compressions and ventilations
Ventilation rate of per minute
Rescuers taught to re-check for signs of circulation “every few minutes”

23. 2 Rescuer CPR with Advanced Airway cont’d
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

24. 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

25. 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

26. “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

27. Adequate vs. Presence or Absence of Breathing cont’d
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

28. 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

29. 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

30. 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 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 and get the AED

31. 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 needed
Victims of hypoxic arrest need immediate CPR

32. “Child” BLS Guidelines
2005 (New):
Child CPR guidelines for healthcare providers apply to victims from 1 year of age to onset puberty (about years old)
2000 (Old):
Child CPR age 1-8

33. “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

34. Symptomatic Bradycardia Infants/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

35. Symptomatic Bradycardia Infants/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

36. 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

37. 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

38. 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 :1 infants/children

39. Compression to Ventilation Ratios Infants/Children cont’d
Why:
Simplify training
Reduce interruptions in chest compressions
15:2 ratio for 2 rescuer CPR for infants/children will provide additional ventilations

40. 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

41. Foreign Body Airway Obstruction cont’d
2005 (New) cont’d
If victim becomes unresponsive
ACTIVATE and begin CPR
When airway opened during CPR, look in mouth and remove object if seen
No blind finger sweeps

42. Foreign Body Airway Obstruction cont’d
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

43. Foreign Body Airway Obstruction cont’d
Why:
Simplification
Compressions during CPR may increase intrathoracic pressure more than abdominal thrusts
Blind finger sweeps may injure victims mouth/throat or rescuers finger

44. 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

45. Shock /Immediate CPR cont’d
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

46. Monophasic Defibrillation dose
2005 (New):
Initial and subsequent shocks for VF/pulseless VT in adults 360J
2000 (Old):
200, J, 360J
Why:
One dose to simplify training

47. Biphasic Defibrillation Dose
2005 (New):
Initial shock for adults: J 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

48. Biphasic Defibrillation Dose cont’d
2000 (Old):
200J, J, 360J
Why:
Simplify defibrillation
Support use of device-specific doses

49. Use of AED’s in Children
2005 (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

50. 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

51. 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

52. Practice