1. The Scientific Foundations Of The American Red Cross CPR Training Standards Paris Hotel and Casino  Las Vegas, Nevada Presented by: Richard N. Bradley, MD

2. Presenter Disclosure Information Richard N. Bradley, MD, LP, FACEP The Scientific Foundations Of The American Red Cross Cpr Training Standards FINANCIAL DISCLOSURE:  No relevant financial relationship (s) exist. UNLABELED/UNAPPROVED USES DISCLOSURE:  No unlabeled/unapproved uses.

3. Objective Understand how the American Red Cross applies science to reach training standards

4. If It Is In Print, It Must Be True Dewey Defeats Truman. Nov 3, 1948. National Archives.

5. Wakefield’s Research – Causes of Autism “We have identified a chronic enterocolitis in children that may be related to neuropsychiatric dysfunction. In most cases, onset was after measles, mumps, and rubella immunisation.”

6. Twelve Years Later

7. How Does The American Red Cross Apply the Science? An example from the medical literature – Traditional evaluation of diagnostic testing --

8. Date of download: 6/3/2014 From: Accuracy of the Papanicolaou Test in Screening for and Follow-up of Cervical Cytologic Abnormalities: A Systematic Review Ann Intern Med. 2000;132(10):810-819. doi:10.7326/0003-4819-132-10-200005160-00009 Copyright © American College of Physicians. All rights reserved.American College of Physicians

9. Measures of A Diagnostic Test Sensitivity and Specificity. Wikipedia.

10. When Should You Start CPR? Adult First Aid/CPR/AED: Ready Reference. American Red Cross, 2011.

11. Application of Diagnostic Testing Condition: Cardiac Arrest Test Outcome: Breathing Assessment Condition: Cardiac Arrest Condition Positive Condition Negative Test Outcome: Breathing Assessment Test Outcome Positive: Not Breathing True PositiveFalse PositivePrecision Test Outcome Negative: Breathing False NegativeTrue Negative Negative Predictive Value SensitivitySpecificity

12. Application of Diagnostic Testing Condition: Cardiac Arrest Test Outcome: Breathing Assessment Condition: Cardiac Arrest Condition Positive Condition Negative Test Outcome: Breathing Assessment Test Outcome Positive: Not Breathing True PositiveFalse PositivePrecision Test Outcome Negative: Breathing False NegativeTrue Negative Negative Predictive Value SensitivitySpecificity These people are in cardiac arrest!

13. Application of Diagnostic Testing Condition: Cardiac Arrest Test Outcome: Breathing Assessment Condition: Cardiac Arrest Condition Positive Condition Negative Test Outcome: Breathing Assessment Test Outcome Positive: Not Breathing True PositiveFalse PositivePrecision Test Outcome Negative: Breathing False NegativeTrue Negative Negative Predictive Value SensitivitySpecificity These people get CPR!

14. Application of Diagnostic Testing Condition: Cardiac Arrest Test Outcome: Breathing Assessment Condition: Cardiac Arrest Condition Positive Condition Negative Test Outcome: Breathing Assessment Test Outcome Positive: Not Breathing True PositiveFalse PositivePrecision Test Outcome Negative: Breathing False NegativeTrue Negative Negative Predictive Value SensitivitySpecificity Gets unnecessary CPR

15. Application of Diagnostic Testing Condition: Cardiac Arrest Test Outcome: Breathing Assessment Condition: Cardiac Arrest Condition Positive Condition Negative Test Outcome: Breathing Assessment Test Outcome Positive: Not Breathing True PositiveFalse PositivePrecision Test Outcome Negative: Breathing False NegativeTrue Negative Negative Predictive Value SensitivitySpecificity In Cardiac Arrest. May die without CPR.

16. Application of Diagnostic Testing The American Red Cross, through the Scientific Advisory Council, applies accepted principles of evaluating diagnostic testing to questions that are important in CPR.

17. AHA 2010 Guideline Change

19. Conscious Adult Foreign Body Airway Obstruction - AHA

20. Conscious Adult Foreign Body Airway Obstruction - ARC Adult First Aid/CPR/AED: Ready Reference. American Red Cross, 2011.

21. Evidence Supporting Back Blows Ruben H, Macnaughton FI. The treatment of food-choking. Practitioner. Nov 1978;221(1325):725-729. 12 humans scheduled for elective surgery were intubated and pressure in the airway was measured with various techniques. Highest airway pressures measured with back blows. Also created a silicone model and found results varied if the obstruction was airtight.

22. Evidence Supporting Back Blows Gordon AS, Belton MK, Ridolpho PF. Emergency management of foreign body obstruction. In: Safar P, Elam JO, eds. Advances in cardiopulmonary resuscitation. New York: Springer-Verlag; 1977:39-50. No studies have been published providing evidence against back blows.

23. Final ARC SAC Recommendations Recommendations and Strength (using table below): Standards:None. Guidelines: 1) Rescuers attempting to resolve a complete airway obstruction in a conscious adult should provide back blows and either abdominal and/or chest thrusts to the victim. 2) Rescuers attempting to resolve a complete airway obstruction in an unconscious adult should provide chest compressions and/or abdominal thrusts. Options:None.

24. Pediatric BLS Algorithm. Reprinted with permission 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Part 13: Pediatric Basic Life Support Circulation.2010;122(suppl 3):S862-S875 ©2010 American Heart Association, Inc.

25. Copyright © American Heart Association, Inc. All rights reserved. Pediatric BLS Algorithm - AHA Reprinted with permission 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Part 13: Pediatric Basic Life Support Circulation.2010;122(suppl 3):S862-S875 ©2010 American Heart Association, Inc.

26. Pediatric BLS Algorithm - ARC Pediatric First Aid/CPR/AED: Ready Reference. American Red Cross, 2011.

27. Compression-only CPR Conventional CPR Conventional CPR vs. compression- only CPR ROSC before hospital arrival 5.3%9.9%2.17 (1.24 – 3.82) 1-month survival8.9%15.9%1.89 (1.23 – 2.91) Neurologically favorable 1-month 1.6%7.2%5.54 (2.52 – 16.99) Evidence Supporting Rescue Breaths in Children

28. Asphyxial cardiac arrest is more common than VF cardiac arrest in infants and children, and ventilations are extremely important in pediatric resuscitation. Animal studies and a recent large pediatric study show that resuscitation results for asphyxial arrest are better with a combination of ventilations and chest compressions. It is, however, unknown whether it makes a difference if the sequence begins with ventilations (ABC) or chest compressions (CAB).

29. Final Determination The American Red Cross standards are based on evidence that more children will survive if lay rescuers provide CPR with rescue breaths and chest compressions.

30. Conclusion Both the American Heart Association and the American Red Cross base training materials on the best science available. Where evidence is inconclusive, there may be differences in training standards based upon professional consensus of the meaning of the available evidence and organizational priorities.

31. Questions Richard N. Bradley, MD, LP, FACEP Richard.N.Bradley@uth.tmc.edu 713-500-7878 redcross.org https://med.uth.edu/emergencymedicine/ https://www.facebook.com/redcross https://www.facebook.com/HoustonEMed