Highlight of American Heart Association for

CPR Cardiopulmonary Resuscitation และ

Emergency Cardiopulmonary Care

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MAJOR CHANGES AFFECTING ALL RESCUERS

The 5 major changes in 2005 guidelines are these:

Emphasis on, and recommendations to improve, delivery of effective chest compressions

A single compression-to-ventilation ratio for all single rescuers for all victims(except newborns)

Recommendation that each rescue breath be given over 1 second and should produce visible chest rise

A new recommendation that single shocks, followed by immediate CPR, be used to attempt defibrillation for VF cardiac arrest. Rhythm checks should be performed every 2 minutes.

Endorsement of the 2003 ILCOR recommendation for use of AEDs in children 1 to 8 years old(and older); use a child dose-reduction system if available.

LAY RESCUER CPR

The major changes in the 2005 guidelines recommendation for lay rescuer CPR are following:

1. If alone with an unresponsive infant or child, give about 5 cycles of  compression and ventilations (about 2 minutes) before leaving the child to phone 911.

2. Do not try to open the airway using a jaw thrust for injured victims—use the head tilt-chin lift for all victims.

3. Take a 5 to 10 second(no more than 10 seconds) to check for normal breathing in an unresponsive adult or for presence or absence of breathing in the unresponsive infant or child.

4. Take a normal (not a deep) breath before giving a rescue breath to a victim.

5. Give each breath over 1 second. Each breath should make the chest rise.

6.If the victim’s chest does not rise when the first rescue breath is delivered, perform the head tilt-chin lift again before giving the second breath.

7. Do not check for signs of circulation. After delivery of 2 rescue breaths, immediately begin chest compressions (and cycles of compressions and rescue breaths).

      8. No teaching of rescue breathing without chest compressions (exception: rescue        breathing is taught in the Heart saver Pediatric First Aid Course).

9. Use the same 30:2 compression-to-ventilation radio for all victims.

10. For children, use 1 or 2 hands to perform chest compressions and compress at the nipple line; for infants, compress with 2 fingers on the breastbone just below the nipple line.

11.When you use an AED, you will give 1 shock followed by immediate CPR, beginning with chest compressions. Rhythm checks will be performed every 2 minutes.

12. Actions for relief of choking (severe airway obstruction) have been simplified.

13. New first aid recommendations have been developed with more information included about stabilization of the head and neck in injured victims.

What did NOT change for lay rescuers:

Checking for response

Location for hand placement for chest compressions in adults

Compression rate

Compression depth for adults, infants, or children (although compression depth for infants and children is no longer listed in inches; it is described only as 1/3 to ½ the depth of the chest)

Ages used for infant, child, and adult CPR recommendations

Key steps for relief of foreign-body airway obstruction (FBAO; choking) for infants, children, or adults

First aid recommendations (minor rewording about stabilization of the head and neck for injured victims)

TABLE 1.Summary of Lay Rescuer CPR for Adults, Children, and Infants

(Newborn/Neonatal information not included)

·        Basic healthcare providers check for “adequate” breathing in adults and presence or absence of breathing in infants and children before giving rescue breaths. Advanced providers will look for “adequate” breathing in victims of all ages and be prepared to support oxygenation and ventilation.

·        Healthcare providers may need to try “a couple of times” to reopen the airway and deliver effective breaths (ie, breaths that produce visible chest rise) for infant and child victims.

·        Excessive ventilation (too many breaths per minute or breaths that are too large or too forceful) may be harmful and should not be performed.

·        Chest compressions are recommended if the infant or child heart rate is less than 60 per minute with signs of poor perfusion despite adequate oxygenation and ventilation. This recommendation was part of the 2000 guidelines but was not emphasized in courses. It will now be emphasized in the courses.

·        Rescuers must provide compressions of adequate rate and depth and allow adequate chest recoil with minimal interruptions in chest compressions.

·        Use 1 or 2 hands to give chest compressions for a child; press on the sternum at the nipple line. For the infant, press on the sternum just below the nipple line.

·        During 2-rescuer infant CPR, the 2 thumb-encircling hands technique should include a thoracic squeeze.

·        Healthcare providers should use a 30:2 compression-to-ventilation ratio for 1-rescuer CPR for victims of all ages and for 2-rescuer CPR for adults. Healthcare providers should use a 15:2 compression-to-ventilation ratio for 2-rescuer CPR for infants and children.

·        During 2-rescuer CPR with an advanced airway in place, rescuers no longer provide cycles of compressions with pauses for ventilation. The compressor provides continuous compressions and the rescuer providing rescue breaths gives 8 to 10 breaths per minute (1 breath about every 6 to 8 seconds).

·        When 2 or more healthcare providers are present during CPR, rescuers should rotate the compressor role every 2 minutes.

·        Actions for FBAO relief were simplified.

What did NOT change:

·        Checking for response

·        Pulse check

·        Rescue breathing without chest compressions

·        Location of hands or fingers for adult chest compressions.

·        Compression rate

·        Compression depth for adults, infants, or children (note that infants and children the depth of compression is listed as one third to one half the depth of the chest and is no longer listed in inches)

·        Ages for use of infant BLS recommendations

Major changes in defibrillation:

Immediate defibrillation is appropriate for all rescuers responding to sudden witnessed collapse with an AED on site (for victims ≥ 1 year of age). Compression before defibrillation may be considered when EMS arrival at the scene of sudden collapse is >4 to 5 minutes after the call.

One shock followed by immediate CPR, beginning with chest compressions, is used for attempted defibrillation. The rhythm is checked after 5 cycles of CPR or 2 minutes.

For attempted defibrillation of an adult, the dose using a monophasic manual defibrillator is 360 J.

The ideal defibrillation dose using a biphasic defibrillator is the dose at which the device waveform has been shown to be effective in terminating VF. The initial selected dose for attempted defibrillation using a biphasic manual defibrillator is 150 J to 200 J for a biphasic truncated exponential waveform or 120 J for a rectilinear biphasic waveform. The second dose should be the same or higher. If the rescuer dose not know the type of biphasic waveform in use, a default dose of 200 J is acceptable.

Reaffirmation of 2003 ILCOR statement that AEDs may b used in children 1 to 8 years of age (and older). For children 1 to 8 years of age, rescuers should use an AED with a pediatric dose-attenuator system if one is available.

Elements of successful community lay rescuer AED programs were revised.

Instructions for shocking VT were clarified.

What did NOT change:

The initial dose for attempted defibrillation for infants and children using a monophasic or biphasic manual defibrillator. First dose 2 J/kg; second and subsequent doses 4 J/kg.

The dose for synchronized cardioversion for infants and children.

The dose for synchronized cardioversion for supraventricular arrhythmias and for stable, monomorphic VT in adults.

Major changes in ACLS include

Emphasis on high-quality CPR. See information in the BLS for Healthcare Providers section, particularly rescue breaths with chest compressions and emphasis on chest compression depth and rate, chest wall recoil, and minimal interruptions.

Increased information about use of LMA and esophageal-tracheal combitube (Combitube). Use of endotracheal intubation is limited to providers with adequate training and opportunities to practice or perform intubations.

Comfirmation of endortracheal tube placement requires both clinical assessment and use of a device (eg, exhaled CO2 detector, esophageal detector device). Use of a device is part of (primary) confirmation and is not considered secondary confirmation.

The algorithm for treatment of pulseless arrest was reorganized to include VF/pulseless VT, asystole, and PEA.

* The priority skills and interventions during cardiac arrest are BLS skills,including effective chest compressions with minimal interruptions.

* Insertion of an advanced airway may not be a high priority.

* If an advanced airway is inserted, rescuers should no longer deliver cycles of CPR. Chest compressions should be delivered continuously (100 per minute) and rescue breaths delivered at a rate of 8 to 10 breaths per minute (1 breath every 6 to 8 seconds).

*Providers must organize care to minimize interruptions in chest compressions for rhythm check, shock delivery, advanced airway insertion, or vascular access.

Intravenous or intraosseous (IO) drug administration is preferred to endotracheal administration.

Treatment of VF/pulse less VT:

* To attempt defibrillation, 1 shock is delivered(see “Defibrillation” for de fibrillation doses using monophasic or biphasic waveforms) followed immediately by CPR (beginning with chest compressions).

* Rescuers should minimize interruptions in chest compressions and particularly minimize the time between compression and shock delivery, and shock delivery and resumption of compressions.

* Compressions should ideally be interrupted only for rhythm check and shock delivery. Rescuers should provide compressions (if possible) after the rhythm check, while the defibrillator is charging. Then compressions should be briefly interrupted when it is necessary to “clear” the patient and deliver the shock, but the chest compressions should resume immediately after the shock delivery.

* Providers do not attempt to palpate a pulse or check the rhythm after shock delivery. If an organized rhythm is apparent during rhythm check after 5cycles (about 2 minutes) of CPR, the provider check a pulse.

* Drugs should be delivered during CPR, as soon as possible after rhythm checks

-If a third rescuer is available, that rescuer should prepare drug doses before they are needed.

- If a rhythm check shows persistent VF/VT, the appropriate vasopressor or antarrhythmic should be administered during the CPR that precedes (until the defibrillator is charged) or follows the shock delivery.

-The timing of drug delivery is less important than is the need o minimize interruptions in chest compressions.

* Vasopressors are administered when an IV/IO line is in place, typically if VF or pulseless VT persists after the first or second shock. Epinephrine may be given every 3 ton 5 minute. A single dose of vasopressin may be given to replace either the first or second dose of epinephrine.

* Antiarrhythmics may be considered after the first dose of vasopressors (typically if VF or pulseless VT persists after the second or third shock). Amiodarone is preferred to lidocaine, but either is acceptable.

Treatment of asystole/pulseless electrical activity: epinephrine may be administered every 3 to 5 minutes. One dose of vasopressin may replace either the first or the second dose of epinephrine.

Treatment of symptomatic bradycardia: the recommended atropine dose is now 0.5 mg IV, may repeat to a total of 3 mg. Epinephrine or dopamine may be administered while awaiting a pacemaker.

Treatment of symptomatic tachycardia: a single simplified algorithm includes some but not all drug that may be administered. The algorithm indicates therapies intended for use in the in-hospital setting with expert consultation available.

Postresuscitation stabilization requires support of vital organs, with the anticipation of postresuscitation myocardial dysfunction. Some reliable prognostic indicators have been reported.

Avoid hyperthermia for all patients after resuscitation. Consider inducing hypothermia if the patient is unresponsive but with an adequate blood pressure following resuscitation.

Thing that did NOT change in ACLS include the following:

·        Most drug doses are the same as those recommended in 2000 (one exception noted above-atropine for bradycardia).

·        The need to search for and treat reversible causes of cardiac arrest and failure to respond to resuscitation attempts. These contributing factors are referred to as the H’s (hypovolemia, hypoxia, hypoglycemia,hypothermia) and T’s (toxins, tamponade, tension pneumothorax, thrombosis [includes coronary or pulmonary], trauma [hypovolemia]). These are listed in the ACLS and PALS algorithms.