1. 2010 American Heart Guideline Update
Karen Manor RN, CEN, CPEN

2. Financial Disclosure
Research nurse with Res-Q Pump study to perform neurological evaluations on subjects in study 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

3. New Category
Level V
Extrapolated from adult data

4. 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

5. 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

6. 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

7. 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

9. 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

10. Pediatric Cardiac Arrest Algorithm

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

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

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

23. 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

24. 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

25. 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

26. 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 J/kg
2 J/kg
Drugs-expert consolation before administration
Amiodorone
Procainamide

27. 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

28. Pacing
No change
Symptomatic bradycardia
Not for asystole or PEA

29. 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

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

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

32. 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

33. 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’

34. 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

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

36. 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

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

38. 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

39. 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

40. PAT-then Primary and Secondary Assessment

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

42. 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

43. 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

44. 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

45. 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

46. Neonatal

47. 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

48. 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

49. 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

50. 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

51. 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

52. 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)

53. What thoughts and concepts we need to work through?

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

55. Contact Information
Karen Manor RN, CEN, CPEN