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ACLS 2010 Updates
Transcript of ACLS 2010 Updates
to no more than 10 seconds ACLS 2010 Update
Highlights Compression Quality
Emphasis is being placed on high quality CPR with compressions of adequate depth (2-2 1/2″) and rate, allowing complete chest recoil. Compression Quality Cardiac arrest algorithms are simplified and redesigned
to emphasize the importance of high-quality CPR (including
chest compressions of adequate rate and depth,
allowing complete chest recoil after each compression,
minimizing interruptions in chest compressions and
avoiding excessive ventilation). High quality CPR continues to be of primary importance in optimizing outcomes. Compression Pauses Minimization of the interval between stopping chest compressions and shock delivery should be encouaged. Data collected has indicated that minimizing the pause between compressions and shock improves the chances of shock success. Ventilation Excessive ventilation can have detrimental effects on the patient who is in cardiac arrest or other low-blood-flow states. Therefore excessive ventilation should be avoided. 2010 AHA Guidelines for CPR and ECC continue to recommend that rescue breaths be given in approximately 1 second The 2010 AHA Guidelines for CPR and ECC once again
emphasize the need for high-quality CPR, including
• A compression rate of at least 100/min (a change from
• A compression depth of at least 2 inches (5 cm) in adults
and a compression depth of at least one third of the anteriorposterior
diameter of the chest in infants and children
(approximately 1.5 inches [4 cm] in infants and 2 inches
[5 cm] in children). Note that the range of 1½ to 2 inches is
no longer used for adults, and the absolute depth specified
for children and infants is deeper than in previous versions of
the AHA Guidelines for CPR and ECC. Continued Emphasis on High-Quality CPR Emphasis is being placed on high quality CPR with compressions of adequate depth (2-2 1/2″) and rate, allowing complete chest recoil. Presented by:
Dr. Ma. Ivy D. Lozada The most dramatic change in the 2010 AHA CPR guidelines for ACLS and BLS is a change in the basic life support sequence of steps from “A-B-C” (Airway, Breathing, Chest compressions) to “C-A-B” (Chest compressions, Airway, Breathing) for adult and pediatric patients (excluding newborns). Sequence Change from ABC to CAB Why: The vast majority of cardiac arrests occur in adults,
and the highest survival rates from cardiac arrest are reported
among patients of all ages who have a witnessed arrest and
an initial rhythm of ventricular fibrillation (VF) or pulseless
ventricular tachycardia (VT). In these patients, the critical
initial elements of BLS are chest compressions and early
defibrillation. In the A-B-C sequence, chest compressions
are often delayed while the responder opens the airway to
give mouth-to-mouth breaths, retrieves a barrier device, or
gathers and assembles ventilation equipment. Per the 2010 Guidelines, it is reasonable for the in-hospital healthcare provider to tailor the sequence of rescue actions to the most likely cause of arrest. Two new parts in the 2010 AHA Guidelines for CPR and ECC are Post–Cardiac Arrest Care and Education, Implementation,and Teams. The importance of post–cardiac arrest care is
emphasized by the addition of a new fifth link in the AHA ECC Adult Chain of Survival Team Delegation Emphasized Why: The number of chest compressions delivered per
minute during CPR is an important determinant of ROSC and
survival with good neurologic function. The actual number of
chest compressions delivered per minute is determined by the
rate of chest compressions and the number and duration of
interruptions in compressions (eg, to open the airway, deliver
rescue breaths, or allow AED analysis). In most studies, delivery
of more compressions during resuscitation is associated with
better survival, and delivery of fewer compressions is associated
with lower survival. Provision of adequate chest compressions
requires an emphasis not only on an adequate compression rate
but also on minimizing interruptions to this critical component of
CPR. An inadequate compression rate or frequent interruptions
(or both) will reduce the total number of compressions delivered
per minute. Why: Although no published human or animal evidence
demonstrates that starting CPR with 30 compressions
rather than 2 ventilations leads to improved outcome, chest
compressions provide the blood flow, and studies of out-ofhospital
adult cardiac arrest showed that survival was higher
when bystanders provided chest compressions rather than no
chest compressions. Animal data demonstrate that delays or
interruptions in chest compressions reduce survival, so such
delays and interruptions should be minimized throughout the
entire resuscitation. Chest compressions can be started almost
immediately, whereas positioning the head and achieving a
seal for mouth-to-mouth or bag-mask rescue breathing all take
time The 2010 AHA ACLS/BLS Guidelines included several points that the AHA felt needed to be emphasized during BLS and ACLS training. Below is a brief summary of these key emphasis points. ACLS Key Emphasis Points for Training -Early recognition of sudden cardiac arrest is of primary importance. It is not uncommon for there to be an abnormal presentation of sudden cardiac arrest which may cause a rescuer confusion and thus delay CPR. Training should include identifying unusual presentations of sudden cardiac arrest so that chest compressions are not delayed.
-Minimize Interruptions in chest compressions. Any unnecessary interruptions in chest compressions decreases CPR effectiveness.
-Minimize the importance of pulse checks. Assessment of a pulse can be very difficult during emergency situations, and often leads to a delay in initiation or continuation of CPR. Chest compressions delivered to patients who are later found not to have been in cardiac Electrical Therapy Changes and Review The 2010 AHA ACLS/BLS guidelines have been updated to reflect new data on the use of pacing in bradycardia, and on cardioversion and defibrillation for tachycardia rhythm disturbance. The following is a list of the most important points. 2010 ACLS Guidelines and Airway Management The 2010 ACLS Guidelines included several changes regarding airway management. Below is a summary of the most significant changes in airway management dynamics: 1. The use of quantitative waveform capnography (QWC) for confirmation and monitoring of endotracheal tube placement is considered a class 1 recommendation. It has been determined that the most reliable method of confirming and monitoring correct placement of an endotracheal tube was QWC. Colormetric ETCO2 devices should only be used “when waveform capnography is not available.
2. The use of supraglottic advanced airways (laryngeal mask airway (LMA), esophageal-tracheal tube (combitube), laryngeal tube) continues to be supported as an alternative to endotracheal intubation for airway management during CPR. When providers are trained in the use of supraglottic airway devices, these devices have been show to be just as effective as a BVM or ET tube for delivery of ventilations.
3. The routine use of cricoid pressure during airway management of patients in cardiac arrest is no longer recommended. Reasons for this include reduced effectiveness of ventilations and interference with placement of a supraglottic airway or intubation. 2010 ACLS Guidelines-Management of Symptomatic Arrhythmias 1. Adenosine can now be considered for the diagnosis and treatment of stable undifferentiated wide-complex tachycardia when the rhythm is regular and the QRS waveform is monomorphic.
2. IV infusion of chronotropic agents is now recommended as an equally effective alternative to external pacing when atropine is ineffective.
3. Atropine is no longer recommended for routine use in the management of PEA and asystole. • The traditional cardiac arrest algorithm was simplified and an
alternative conceptual design was created to emphasize the
importance of high-quality CPR. Elimination of “Look, Listen, and Feel
2010 (New): “Look, listen, and feel for
breathing” was removed from the sequence for assessment of breathing after opening the airway. The healthcare provider briefly checks for breathing when checking
responsiveness De-emphasis of Devices, Drugs, and
Other Distracters Emphasis has been placed on delivery of high-quality
CPR and early defibrillation for VF/pulseless VT. Vascular access, drug delivery, and advanced airway placement, while still recommended, should not cause significant interruptions in chest compressions and should not delay shocks 2010 (New): Post–Cardiac Arrest Care is a new section
in the 2010 AHA Guidelines for CPR and ECC. To improve
survival for victims of cardiac arrest who are admitted to a
hospital after ROSC, a comprehensive, structured, integrated,
multidisciplinary system of post–cardiac arrest care should be
implemented in a consistent manner (Box 3). Treatment should
include cardiopulmonary and neurologic support. Therapeutic
hypothermia and percutaneous coronary interventions (PCIs)
should be provided when indicated (see also Acute Coronary
Syndromes section). Because seizures are common after
cardiac arrest, an electroencephalogram for the diagnosis
of seizures should be performed with prompt interpretation
as soon as possible and should be monitored frequently or
continuously in comatose patients after ROSC Organized Post–Cardiac Arrest Care Improved outcomes for ACLS are expected when ACLS is performed by an integrated team of highly trained rescuers. Having a team of highly trained rescuers allows for efficient management of the many tasks performed by healthcare providers during a resuscitation attempt. Thus, training should focus on building the team as each member arrives or quickly delegating roles when multiple rescuers are present. 1. Full integration of AED’s into a system of care is critical to the Chain of Survival in public places outside hospitals.
2. The 1-shock protocol for VF has not been changed.
3. Rescuers should minimize the interval between stopping compressions and delivering shocksand should resume CPR immediately after the shock delivery
4. Biphasic waveforms have been shown to be more effective than monophasic waveforms in cardioversion and defibrillation. Emphasis should be placed on the use of the biphasic waveform.
5. In both defibrillation and cardioversion, if the initial shock fails, providers should increase the dose in a stepwise fashion.
6. Pacing is not recommended for patients in asystolic cardiac arrest.
7. Healthcare providers should be prepared to initiate pacing in patients with bradyarrhythmias in the event the heart rate does not respond to atropine or other chronotropic (rate accelerating) drugs.