2010 American Heart Guideline Update Karen Manor RN, CEN, CPEN

Financial Disclosure Research nurse with Res-Q Pump study to perform neurological evaluations on subjects in study 2005-2010 employed by Advanced Circulatory Systems As AHA mentioned Not FDA approved use of therapeutic hypothermia in children Not FDA approved use of Amiodorone in children

New Category Level V Extrapolated from adult data

BLS Sequence Peds Recognize apnea or abnormal breathing Call 911 and AED-if lone provider call for help after 2 minutes of CPR Check pulse (<10 seconds) 30:2 Use AED when it arrives Pulse check is deemphasized Often done for too long Ok to do CPR with a pulse Chest compression depth 1.5 inches infant 2 inches child At least 2 “ adolescents

High Quality CPR Cornerstone of Resuscitation 2005 Guidelines 2010 Guidelines ABC Airway Breathing Circulation Compressions CAB Chest Compressions Airway Breathing Priorities Allow complete chest recoil Minimizing interruptions in chest compressions Avoiding excessive ventilations

Push Hard and Push Fast Out of hospital arrest 20-30% adults receive bystander CPR Imperative for survival to have CPR started immediately Hands only technique simpler

Hand Only CPR in Children Japan has large group that does hands only CPR on children Conventional CPR 7.2% favorable neurological outcome Hands only CPR 1.6% favorable neurological response IF cardiac cause Conventional CPR 9.9% outcome Hands only CPR 8.9% outcome

Specifics Spend less time discerning person in extremis Dispatcher directed or lay person No look listen or feel for breathing Loss of consciousness Absent breathing, gasping (not abnormal breathing in peds) seizures Healthcare provider-check for pulse < 10 seconds

Pediatric Cardiac Arrest Algorithm

Compressions 2005 Guidelines 2010 Guidelines Approximately 100 per minute Mid-nipple line ½-1/3 the depth of the chest-infant/child Recoil of chest discussed Keep interruptions < 10 seconds Change compressors q 2 minutes At least 100/ minute-stay tuned for what the upper limit maybe Center of sternum 1 ½-2 inches infant/child Recoil of chest imperative Interruptions < 5-10 seconds Interruption 24-57% of time Change compressor at least q 2 minutes Position compressors on either side of patient Guidelines out of hospital for adults to stop CPR to avoid ineffective dangerous CPR en route

Airway Lay person Healthcare Provider Head tilt-chin lift Spinal cord injury suspected Jaw thrust Head tilt-chin lift if jaw thrust not adequate Spinal immobilization can interfere with maintaining airway Manual hand placement Use immobilization devices during transport

Breathing Untrained lay rescuer Trained rescuer Healthcare provider Hands only CPR Push hard and fast Trained to stop when higher level of care arrives Trained rescuer 30:2 No 2 man CPR Healthcare provider “Reasonable to provide chest compressions and rescue breaths” Felt to be unreasonable for single HCP to do 1 man CPR with bag valve mask

Breathing Adult Unresponsive No breathing Agonal breathing Child Funny breathing Child Unresponsive No breathing Not taught to look for funny or agonal breathing as some kids normally breath this way

Breathing No look listen or feel for breathing anymore Breath over 1 second With mouth to mouth give regular breath to avoid rescuer hyperventilation Less likely to use barrier device Tidal volume to produce visible chest rise Stomal rescue breaths-use pediatric face mask 30:2 When advanced airway without pulse breath q 6-8 seconds q 10 breaths/minutes

Breathing Breathing with advanced airway Cricoid pressure At least 100 compressions per minute 1 breath q 6-8 seconds Cricoid pressure can delay or prevent placement of advance airway in adults Aspiration is not prevented as previously thought Routine use not recommended in adults Can be used with an additional provider in children Do not press too hard too prevent air movement into the trachea Can use to aid in tracheal intubation Excessive breathing Gastric inflation Increases intrathoracic pressure→ ↓venous return ↓ cardiac output ↓ survival

Breathing with a pulse Adult 2005 Guidelines Adult 2010 Guidelines Rescue breathing every 5 seconds Children/infants every 3-5 seconds Rescue breathing every 5-6 seconds Children/infants every 3-5 seconds

New Ways to Assess Effectiveness of Resuscitation Both of these can indicate ROSC without stopping CPR to check a pulse Arterial Line End title CO2 10-15 suggest good CPR Gastric contents unreliable with acidic drugs and Epi given IV Epi ↓pulmonary blood flow Severe airway issues with obstruction such as asthma can affect numbers

Capnography (Adult and Child) 2005 Guidelines 2010 Guidelines Exhaled CO2 detector or esophageal detector device to confirm endotracheal tube (ET) placement Monitoring can be useful as a noninvasive indicator of cardiac output in CPR Recommended during the periarrest period Prehospital →ICU Uses include Confirmation of ET placement Monitoring CPR quality Detecting ROSC Monitoring of ET placement It is the most reliable way to confirm and monitor ET placement

Fluid Resuscitation 3rd bolus blood (10 ml/kg) or fluid Or early use of blood products O- for females O+ for males

ECMO Consider early if refractory to standard attempts Good neurological outcomes even with CPR >1 hour

AED Goal to defibrillate within 3 minutes Even in hospitals Staff that does not have rhythm recognition Takes longer to get code cart to scene Use pediatric pads < 8 years of age if possible Use in infants Prefer manual if possible Use AED if necessary

Pad Placement 2005 Guidelines 2010 Guidelines Anterior-lateral position Implantable defibrillator/pacemaker Place pad at least 1” away from device Anterior-lateral position Only correct placement in PALS Anterior-posterior Anterior-left scapular Anterior-right infrascapular Implantable defibrillator/pacemaker Do not delay defibrillation Try to avoid placing pads directly over the device

Drug Therapy 2005 Guidelines 2010 Guidelines Atropine-PEA/Asystole Q 3-5 minutes-adults Adenosine-narrow fast complex Chronotropic drugs may be used while awaiting pacer or pacing was ineffective Atropine-PEA/Asystole Not in algorithm anywhere Adenosine-now for narrow REGULAR wide complex Adult and children Chronotropic drugs work as well as pacing when Atropine has been ineffective-in adults

Supraventricular Tachycardia (SVT) 2005 guidelines Vagal maneuvers Adenosine Synchronized cardiovert 2010 guidelines Vagal maneuvers Ice to face Straw Carotid massage-older child Adenosine Synchronized cardiovert 0.5-1 J/kg 2 J/kg Drugs-expert consolation before administration Amiodorone Procainamide

Stable Ventricular Tachycardia (V Tach) 2005 Guidelines 2010 Guidelines Not enough evidence for a recommendation Expert consultation Amiodorone Procainamide Synchronized cardioversion 0.5-1 J/kg 2 J/kg

Pacing No change Symptomatic bradycardia Not for asystole or PEA

Pediatric Advanced Life Support (PALS) 2005 Guidelines 2010 Guidelines Defibrillation dose 1st dose 2 joules/kilogram 2nd and subsequent dose 4 joules/kilogram Wide complex >.08 Hypothermia s/p resuscitation d/t cardiac cause maybe helpful Defibrillation dose 1st dose 2-4 joules/kilogram Teach 2 J/kg 2nd dose 4-10 joules/kilogram Teach then go to 4J/kg Do not exceed adult doses Lethal dose in child in VF-0 Wide complex >.09 (16 yr or less) Consider therapeutic hypothermia for ROSC who remain comatose s/p cardiac arrest

ET Tube Formulas now for both cuffed and uncuffed 4+age/4 uncuffed

In-Hospital Death Between Hyperoxia and Normoxia Kilgannon, J. H. et al. JAMA 2010;303:2165-2171. Copyright restrictions may apply.

PALS 2005 Guidelines 2010 Guidelines Calcium can be used in arrest situation Etomidate-minimal hypotensive effect with RSI Calcium administration in cardiac arrest may have benefit Known hypocalcemia Known calcium channel blocker overdose Hyper magnesia/kalemia Etomidate should not be used in suspected shock

Ethical Issues DNAR-Do Not Attempt Resuscitation Does not preclude Parental fluid Nutrition Oxygen Analgesia Sedation Antiarrhythmics Vasopressors Unless they are included in the order Allow Natural Death (AND) Never ‘slow code’

Post Resuscitation Consider hypothermia if not awake and able to follow simple commands-especially after sudden cardiac arrest Monitor for s/s seizures/ agitation EEG to look for s/s seizures if paralyzed

Post Resuscitative Care Return of ROSC after pre-hospital VF arrest EKG maybe unreliable Should have consideration of immediate angiography and PCI

Post Resuscitation Care Status Post Hypothermic Care Old ways of testing to evaluate neurological recovery do not work Need to wait 72 hours before can predict neurological recovery More studies are needed

Sudden Death Especially in older children Postmortem with ME specialized in looking for chanellopathy

Drowning Start mouth to mouth in the water Delay chest compression until out of water Lone rescuer once on land perform 5 cycles of CPR (2 minutes) before calling 911 Spinal cord injury is rare Remove from water ASAP Unless signs of intoxication history of shallow water diving

Foreign Body Obstruction Infant Back slaps and chest thrusts Child and Adult Abdominal thrusts until unresponsive Then CPR with visual look in mouth before respirations 50% of episodes by the time EMS was summoned airway obstruction was relieved 0f the 50% that were not relieved EMS was able to remove 85% <4% died Once unresponsive chest thrust with CPR generated higher airway pressures than abdominal thrusts No blind finger sweep

PAT-then Primary and Secondary Assessment

Neonatal Resuscitation (NRP) The order is still A B C

Neonate Definition of neonate quite gray-at least through first admission 3:1 Unless cardiogenic cause or maybe 3 day old in PICU 15:2

NRP 2005 Guidelines 2010 Guidelines 3:1 CPR Therapeutic hypothermia is an area where research is needed 3:1-unless arrest felt to be cardiac in nature then 15:2 two rescuer 30:2 one rescuer ≥ 36 weeks evidence of moderate to severe anoxic encephalopathy therapeutic hypothermia is beneficial

NRP 2005 Guidelines 2010 Guidelines Clamp umbilical cord upon delivery Preterm and full turn infants that do not require resuscitation Delay cord clamping for one minute Infants that require resuscitation there is no guideline

NRP Once start positive pressure ventilation (PPV) Use room air, not supplemental oxygen at first Assess the following to ensure improvement Heart rate Respiratory rate Evaluation state of oxygenation Preferably by oxygen saturation not color Use pulse ox probe to right upper extremity Do not suction the airway unless has obvious obstruction including meconium babies who are nonvigorous

Neonatal

New Terms Hyperoxemia-increased content of the blood Apoptosis-process of programmed cellular death (PCD) Cycle Duty-set of 2 minutes of CPR Channelopathy-genetic mutations that cause cardiac ion transport defects

Timeline October 18, 2010 release in Circulation November 10 national faculty training in Chicago November 12 1st instructor training in Chicago December/January on line for training instructors March 1, 2011 all instructors have gone through on-line or in person science update

Release of New Content 1st quarter new BLS material 2nd quarter ACLS material 3rd quarter PALS and later PEARS ACLS EP mid to late 2011

When to teach new material March 1, 2011 is when new bridging science material is to be used into the classroom 3rd quarter move to new material Once new content is release 60 day window to transition to new material All instructors are required to have their update done before using bridging material

What is needed to teach with bridging materials 2006 Instructor Manual 2010 Highlights 2010 ECC handbook 2010 skills sheet-will be available on instructor network CAB sequence video for CPR-from instructor network Updated science video-available from instructor network Skills test for CPR and written test-from training center Errata sheet to update lesson maps All instructors gone through update on instructor network

What students need for bridging class 2006 PALS provider manual 2010 guidelines that can be downloaded Errata for the PALS provider manual 2010 ECC handbook 2010 AHA guidelines for CPR (optional)

What thoughts and concepts we need to work through?

Reference Circulation 2010; 122 S640-933 Kilgannon, J.H., Jones, A.E., & Shapiro, N.I et al. (2010) JAMA 304 (13) 2165-2171.

Contact Information Karen Manor RN, CEN, CPEN Karen.J.Manor@HealthPartners.com 651-254-7782