Understanding the 2010 CPR/ECC and First Aid Guidelines

1. Understanding the 2010 CPR/ECC and First Aid Guidelines David C. Berry, PhD, LAT, ATC Associate Professor and Athletic Training Program Director Department of Kinesiology Saginaw Valley State University University Center, MI

2. Objective • Examine the 2010 CPR, Emergency Cardiac Care (ECC) and First Aid treatment guidelines and recommendations and the rational and science behind these suggested changes.

3. International Liaison Committee on Resuscitation (ILCOR) Representatives1 Resuscitation Council of Asia Heart and Stroke Foundation of Canada European Resuscitation Council American Heart Association InterAmerican Heart Foundation Australian/New Zealand Committee on Resuscitation Resuscitation Council of Southern Africa

4. CPR-ECC Review Process

5. CPR-ECC Review Process • Individual organizations draft their specific guidelines for their population served, remembering to clarifying the most important skills needed to perform in an emergency situation to improve patient outcomes.

6. First Aid Review Process • National First Aid Science Advisory Board (Co-founded by the AHA and ARC) reviewed and evaluated the scientific literature regarding first aid treatment guidelines.2 • Similar process to CPR-ECC guidelines; however, this review was the most compressive review ever completed looking to answer ……

7. First Aid Review Process

8. Lay Rescuer CPR/ECC Key Recommendations and Guidelines

9. Chain of Survival3

10. Chain of SurvivalPost-Cardiac Arrest Care • Designed to emphasize protocols for optimizing cardiovascular and neurological function to improve survival of victims with resumption of spontaneous circulation (ROSC) after cardiac arrest.1 • Includes- • Optimizing cardiopulmonary function/vital organ perfusion after ROSC. • Transporting to an appropriate hospital/critical care unit with a comprehensive post–cardiac arrest treatment system. • Identify and treat ACS and other reversible causes. • Control temperature to optimize neurologic recovery • Anticipate, treat, and prevent multiple organ dysfunction. This includes avoiding excessive ventilation and hyperoxia.

11. Simplified ILCOR Universal Adult BLS Algorithm1

12. Simplified Universal Adult BLS Algorithm4 American Heart Association

13. Emphasis on Chest Compressions New for 2010 • Bystanders NOT trained in CPR should provide Hands-Only™ (compression-only) CPR for the adult patient who suddenly collapses, with an emphasis to “Push Hard and Fast” on the center of the chest. • Continue Hands-Only™ CPR until- • AED arrives and is ready for use or • EMS or another responder(s) takes over care.

14. Emphasis on Chest Compressions Why Change? • Compression-only bystander CPR has been shown to substantially improve survival following adult out-of-hospital cardiac arrests compared with NO bystander CPR.5-8

15. Emphasis on Chest Compressions How can bystander CPR be effective without rescue breathing? • During SCA (with VF), rescue breaths initially are not as important as chest compressions because the oxygen level in the blood remains adequate for the first several minutes after cardiac arrest.4 • Animal models suggest gasping or agonal gasps do allow for some oxygenation and carbon dioxide (CO2)elimination.9-10

16. “C-A-B” rather than “A-B-C” New for 2010 • Initiate chest compressions before ventilations. Why Change? • Beginning CPR with 30 compressions rather than 2 ventilations leads to a shorter delay to first compression11-13 providing vital blood flow to the heart and brain.

17. Elimination of “Look, Listen, and Feel” New for 2010 • “Look, listen, and feel” was removed from the CPR sequence. • After delivery of 30 chest compressions, the lone rescuer will open the airway and deliver 2 breaths, each for 1 second. Why Change? • With the new “chest compressions first” sequence, CPR is performed if the adult is unresponsive and not breathing or not breathing normally.3 • Look, Listen and Feeling is also inconsistent and time consuming.

18. Chest Compression Rate“At Least 100 per Minute” New for 2010 • Reasonable for lay rescuers to perform chest compressions at a rate of at least100 compression/min. Why Change? • More adequate chest compressions per minute was associated with higher survival rates • Fewer compressions were associated with lower survival rates.14-15

19. Chest Compression Depth New for 2010 • Adult and child sternum should be depressed at least 2 inches (5 cm). • Infant sternum should be depressed at least 1 ½ inches (4 cm). Why Change? • Science suggests that compressions of at least 2 inches was more effective than compressions of 1 ½ inches.16-18 • Believed confusion exists when a depth range is recommended, so 1 compression depth is now recommended for all ages.

20. Healthcare Provider CPR/ECC Recommendations and Guidelines

21. Healthcare Provider Adult BLS Algorithm4

22. Emphasis on Chest Compressions New for 2010 • Effective chest compressions are emphasized, but optimally all healthcare providers should be trained in BLS, thus it is reasonable to provide chest compressions and rescue breaths for cardiac arrest victims. Why Change? • Healthcare providers should be trained to perform both compressions and ventilations.3 • If healthcare providers are unable to perform ventilations, the provider should activate the emergency response system and provide chest-only compressions.

23. Activation of Emergency Response System New for 2010 • Healthcare providers should check for response while looking at the patient to determine if breathing is absent or not normal. Why Change? • Healthcare providers should not delay activation of the emergency response system but should obtain 2 pieces of information simultaneously: • Responsiveness • No breathing or no normal breathing.4

24. Cricoid Pressure New for 2010 • The routine use of cricoid pressure for patient of cardiac arrest is NOT recommended. Why Change? • RCTs demonstrated cricoid pressure delayed or prevented placement of an advanced airway and that aspiration may occur even with application of pressure.26-29 • Manikin studies30-32 found the maneuver difficult for both expert and nonexpert rescuers.

25. Healthcare Provider and Lay Rescuer Consistent Adult Changes • Change in CPR Sequence- • C-A-B Rather Than A-B-C • Chest Compression Depth • Adult sternum should be depressed at least 2 inches (5 cm). • Chest Compression Rate • At Least 100/minute

26. Key BLS Components for Adult, Children, and Infants3

27. Key BLS Components for Adult, Children, and Infants3

28. Electric TherapiesAdult • The 2010 International Consensus on Science With Treatment Recommendations statement contains no major differences or dramatic changes for adult defibrillation compared to the 2005 International Consensus statement.33

29. Electric TherapiesPediatric New for 2010 • A pediatric dose-attenuator AED should be used for children ages 1-to-8. • For infants (<1 year of age), a manual defibrillator is preferred. • If neither unit is available, an AED without a dose attenuator may be used for both age groups. Why Change? • AEDs with relatively high-energy doses (as high as 9 J/kg) have been used successfully for infants in cardiac arrest with no clear adverse effects.34

30. Electric TherapiesShock First vs. CPR First Reaffirmation 2010 • When SCA is witnessed and an AED IS immediately available, rescuers should start CPR with chest compressions and use the AED as soon as possible. • When SCA is not witnessed initiate CPR while checking and preparing for defibrillation. • Whenever 2 or more rescuers are present, CPR should be provided while the defibrillator is retrieved.3

31. Electric TherapiesElectrode Placement New for 2010 • The anterior-lateral pad position is the default electrode placement when using an AED. • However, any of 3 alternative pad positions may be used- • Anterior-posterior • Anterior–left infrascapular • Anterior–right infrascapular Why Change? • Studies suggest that all 4 AED pad placements were equally effective in defibrillation for VF.35-38

32. First Aid Recommendations and Guidelines

33. Supplemental (Emergency) Oxygen No Change From 2005 • Administration of oxygen is not recommended for patients with shortness of breath or chest discomfort. New for 2010 • Supplementary oxygen administration should be considered as part of first aid for divers with a decompression injury. Why Change? • No benefit of supplementary oxygen administration was found in treating patients with shortness of breath or chest discomfort.39-41 • Evidence that supplementary oxygen for divers with decompression injury may be effective.42

34. Epinephrine and Anaphylaxis New for 2010 • Recommended that if the symptoms of anaphylaxis persist despite administration of an Epi-pen, rescuers should seek medical assistance before administering a 2nd dose of epinephrine. Why Change? • Approximately 18% to 35% of patients presenting with signs and symptoms of anaphylaxis may require a 2nd dose of epinephrine,43-45 however the diagnosis of anaphylaxis can be a challenging and excessive epinephrine administration may produce complications.2

35. Aspirin Administration for Chest Discomfort New for 2010 • Rescuers should advise the patient to chew 1 adult (non-coated) or 2 lowdose “baby” aspirins if the patient has- • No allergy to or other • Contraindications to aspirin (e.g., stroke or recent bleeding).46-48 Why Change • Aspirin is beneficial when chest discomfort is due to an acute coronary syndrome (ACS), however, the administration of aspirin must never delay EMS activation.2

36. Bleeding ControlTourniquets No Change From 2005 • The use of a tourniquet to control bleeding of the extremities is indicated ONLY IF direct pressure is NOT effective or possible and if the provider has PROPERLY trained in tourniquet use.

37. Bleeding ControlHemostatic Agents New for 2010 • The routine use of hemostatic agents to control bleeding as a first aid measure is NOT recommended at this time for lay responders, but may be considered if direct pressure and tourniquets are not possible for professional rescuers.2

38. Bleeding ControlPressure Points and Elevation Reaffirmation • Elevation and pressure points are not recommended to control bleeding.2 Why Change? • This recommendation is made because there is evidence that other methods of controlling bleeding are more effective2 and as of 2010 no studies had examined the hemostatic effects of elevation to control bleeding.

39. Bleeding ControlShock New for 2010 • If a victim shows evidence of shock, have the victim lie supine, DO NOT elevate the feet. Why Change? • Simplified decision-making. • There are no studies examining the effects of leg position (elevation) as a first aid maneuver for the management of shock.2

40. Animal BitesSnakebites New for 2010 • Care of any venomous snake bite is now consistent. • Place a pressure bandage around the length of the bitten extremity with pressure applied between- • 40-70 mm Hg in the upper extremity • 55-70 mm Hg in the lower extremity Why Change • Effectiveness of pressure immobilization has been shown to be effective and safe in slowing lymph flow and the dissemination of snake venom.49-51

41. Animal BitesJellyfish New for 2010 • To inactivate venom and prevent further envenomation, stings should be liberally washed with vinegar (4-6% acetic acid solution) quickly and for at least 30 secs. • Once nematocysts are removed/deactivated, the pain should be treated with hot-water immersion. Why Change? • Evidence suggests that vinegar is most effective solution for inactivation of the nematocysts. 52-55 • Immersion with water, as hot as tolerated for about 20 minutes, is most effective for treating the pain.52-55

42. Environmental Emergencies Heat Stroke New for 2010 • The most important action to manage heat stroke is to begin immediate cooling, preferably by immersing the victim up to the chin in cold water.56-58 • It is also important to activate the EMS system as heat stroke requires emergency treatment with intravenous fluids.2 • Do not try to force the victim to drink liquids if they have altered mental status.2

43. Environmental Emergencies Frostbite New for 2010 • Better distinction between recognition and care for minor and severe frostbite. • Care - minor • Skin-to-skin contact • Care – severe • Rewarmed by immersing extremity in warm (98.6° to 104°F or approximately body temperature) water for 20 to 30 minutes.2 • Chemical warmers should not be placed directly on frostbitten tissue because they can reach temperatures that can cause burns.59

44. Spinal Stabilization New for 2010 • Maintain spinal motion restriction by manually stabilizing the head so that the motion of head, neck, and spine is minimized.2 • Providers should not use immobilization devices because their benefit in first aid has not been completely proven and they may be harmful.2 • However, if needed, providers should be properly trained in their use.2

45. Ingest PoisonsTreatment With Milk or Water New for 2010 • There is insufficient evidence to show that milk or water dilution of ingested poisons produces any benefit as a first aid measure.2 • Possible adverse effects of water or milk administration include emesis and aspiration.

46. Ingest PoisonsActivated Charcoal and Ipecac • Do Not administer activated charcoal to a patient ingesting a poisonous substance unless advised by poison control center or emergency medical personnel.2 • Activated charcoal is safe to administer60-61 but no evidence to suggest that it is effective as a component of first aid. • Do Not administer syrup of ipecac for ingestions of toxins as there is no advantage to administering syrup of ipecac and it may delay care in an advanced medical facility.

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