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

• ABC• Airway• Breathing • Circulation• Compressions

2010 Guidelines

• 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– 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

2010 Guidelines– 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– Head tilt-chin lift

• 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 – Hands only CPR– Push hard and fast– Trained to stop when higher level of care arrives

• Trained rescuer– 30:2– No 2 man CPR– Trained to stop when higher level of care arrives

• 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

– Funny breathing

• No 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

– 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

Breathingwith a pulse

Adult 2005 Guidelines• Rescue breathing every 5

seconds

• Children/infants every 3-5 seconds

Adult 2010 Guidelines• 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• 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

2010 Guidelines• 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• Anterior-lateral position

• Implantable defibrillator/pacemaker– Place pad at least 1”

away from device

2010 Guidelines• 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• Atropine-PEA/Asystole

– Q 3-5 minutes-adults• Adenosine-narrow fast

complex

• Chronotropic drugs may be used while awaiting pacer or pacing was ineffective

2010 Guidelines• 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 cardiovert0.5-1

J/kg2 J/kg

• Drugs-expert consolation before administration– Amiodorone– Procainamide

Stable Ventricular Tachycardia(V Tach)

2005 Guidelines• Not enough evidence for

a recommendation

2010 Guidelines• 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 GuidelinesDefibrillation 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

2010 GuidelinesDefibrillation 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• 3.5+age/4 uncuffed

Copyright restrictions may apply.

Kilgannon, J. H. et al. JAMA 2010;303:2165-2171.

In-Hospital Death Between Hyperoxia and Normoxia

PALS

2005 Guidelines• Calcium can be used in

arrest situation

• Etomidate-minimal hypotensive effect with RSI

2010 Guidelines• 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• Nutrition• 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 PICU15:2

NRP

2005 Guidelines• 3:1 CPR

• Therapeutic hypothermia is an area where research is needed

2010 Guidelines• 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• Clamp umbilical cord

upon delivery

2010 Guidelines• 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