changes in BLS, ACLS & PALS from By the end of this program, the

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1 2010 AHA BLS, ACLS & PALS Changes: What s New? Jennifer Murray MSN, RN Critical Care Educator AHA Training i Center Coordinator PALS Regional Faculty ACLS Training Center Faculty

2 Objectives This module will only cover the changes in BLS, ACLS & PALS from the 2005 to 2010 guidelines. By the end of this program, the learner should: Be able to state the changes made in emergency cardiovascular care algorithms

3 2010 Highlights of BLS Look, listen and feel removed from the algorithm due to delays in CPR Early activation at of EMS High quality CPR Minimize compression interruptions De-emphasis on pulse checks during CPR due to interrupting CPR Cricoid pressure no longer recommended for use with ventilation

4 CAB not ABC BLS Chest compressions, Airway, Breathing (CAB) Most arrests are adults and most survivors are VF/VT Emphasis on performing high quality CPR and early defibrillation Delay in C when attempting A

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6 BLS New science indicates the following order for Healthcare providers: Check the pt. for responsiveness & presence/absence of breathing or gasping Call for help Check the pulse for no more than 10 seconds Give 30 compressions Open airway and give 2 breaths/ventilations Resume compressions

7 BLS Take no longer than 10 seconds to check for a pulse. If no pulse detected within 10 seconds, begin chest compressions!!! Compression rate at least 100/minute, so each set of 30 compressions should take ~18 seconds or less.

8 BLS 30 compressions : 2 breaths Compression depth: Adults: At least 2 inches (5cm) Children: At least 1/3 depth of the chest, ~2 inches (5 cm) Infants: At least 1/3 depth of the chest, ~1.5 inches (4 cm)

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10 BLS

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12 2010 Highlights of ACLS Changes Successful ACLS is predicated on good BLS High quality CPR with minimal interruptions Early defibrillation Fifth link in Chain of Survival : Post Cardiac Arrest Care Multidisciplinary care from BLS to discharge for good neurologic outcome Qualitative waveform Capnography

13 ACLS: Airway & Breathing Continuous quantitative capnography is now recommended for intubated patients throughout the peri-arrest period. Capnography p is also recommended for confirmation of ETT placement & for monitoring CPR If PETCO2 is <10 mmhg, then attempt to improve CPR quality

14 ACLS: Airway & Breathing ETCO2 Capnography: Persistently low PETCO2 values <10 mmhg during CPR, in the intubated patient, suggest that Return of Spontaneous Circulation (ROSC) is unlikely If PETCO2 abruptly increases to normal value of mmhg, it is reasonable to consider this an indicator of ROSC

15 ACLS: Airway & Breathing Once ROSC occurs, arterial oxyhemoglobin saturation should be monitored, and titrate O2 to maintain this to >94% Supplementary O2 is not needed for pts. without evidence of respiratory distress or when oxyhemoglobin saturation is >94%

16 ACLS: Pharmacology Atropine is NOT recommended for routine use in PEA/asystole and has been removed from the algorithm!!! Adenosine may be considered in the initial diagnosis of stable, unidifferentiated, regular, monomorphic, wide-complex tachycardia Do not use if pattern is irregular

17 ACLS: Pharmacology For treatment of symptomatic & unstable bradycardia, chronotropic drug infusions are recommended as an alternative to pacing (dopamine or epinephrine drip) Morphine should be given with caution to patients with unstable angina

18 ACLS: Defibrillation/Cardioversion Cardioversion A. fib J biphasic and 200J monophasic A flutter & other supraventricular J biphasic and monophasic (requires less energy than a fib) **If the initial cardioversion shock fails, providers should increase the dose in a stepwise fashion

19 ACLS: Defibrillation/Cardioversion Monomorphic V tach Cardioversion Initial energy of 100J in biphasic and monophasic If no response to initial shock, then increase dose in a stepwise fashion

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22 ACLS: Post Resuscitation Care New Section improving survival after ROSC returns include: Optimizing cardiopulmonary function & vital organ (brain and heart) perfusion Transporting out of hospital arrest to facility with acute coronary interventions, neurologic care, goal directed critical care & hypothermia Transporting in hospital arrest to the critical care unit capable of providing comprehensive post cardiac arrest care

23 CONT. IDing and treating the causes of the arrest and preventing recurrence Considering therapeutic hypothermia to optimize survival and neurological recovery in comatose patients IDing and treating acute coronary syndromes Optimizing i i mechanical ventilation to minimize i i lung injury Gathering data for prognosis Assisting patients & families with rehabilitation services if needed

24 ACLS: Post Cardiac Arrest Care Critical actions for post-cardiac arrest care: Hemodynamic optimization, including a focus on treating hypotension Acquisition of 12 lead ECG Induction of therapeutic ti hypothermia Monitoring advanced airway placement & ventilation status with quantitative waveform capnography in intubated patients Optimizing arterial oxygen saturation

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26 ACLS:Bradycardia Heart rate parameter is now <50 bpm Always assess clinical condition Atropine is 1 st line treatment Chronotropic drug IV infusion is equally as effective to external transcutaneous pacing when atropine is ineffective

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28 ACLS: Tachycardia with a Pulse Adenosine: 1 st dose = 6 mg IVP; 2 nd dose = 12 mg IVP Reduce initial dose to 3mg if pt. has CVL Does NOT convert a fib a flutter or Does NOT convert a fib, a flutter or Vtach

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30 2010 Highlights of PALS Changes

31 PALS: Airway and Breathing Once circulation is restored, monitor oxyhemoglobin saturation. Titrate O2 to maintain >94%. **An oxyhemoglobin saturation of 100% is generally an indication to wean the FiO2. Exhaled CO2 detection is recommended in addition to clinical assessment to confirm ETT placement in neonates, infants & children with a perfusing cardiac rhythm in all settings (prehospital, ED, ICU, ward, OR) Cricoid pressure is not routinely recommended during Intubation.

32 PALS: Defibrillation Initial dose for defibrillation is now 2-4 J/kg, instead of starting at 2 J/kg For refractory vfib, it is reasonable to increase the dose to 4 J/kg Subsequent energy levels l should be at least 4 J/kg High levels (not to exceed 10 J/kg or High levels (not to exceed 10 J/kg or adult max dose) may be considered

33 PALS: ECG Wide complex tachycardia is present if the QRS width is > second

34 PALS: Pharmacology Routine calcium c administration at is NOT recommended for pediatric cardiopulmonary arrest in the absence of documented hypocalcemia, calcium channel blocker OD, hypermagnesemia or hyperkalemia Etomidate has been shown to facilitate ETT intubation in infants/children with minimal i hemodynamic effect, but it is NOT recommended for use in ped patients with evidence of septic shock

35 PALS: Post Cardiac Arrest Care Although there have been no published results of prospective randomized pediatric trials of therapeutic hypothermia, based on adult evidence, therapeutic hypothermia (32 degrees C 34 degrees C) may be beneficial for adolescents who remain comatose after resuscitation from sudden witnessed out of hospital vfib Therapeutic hypothermia may also be considered for infants and children who remain comatose after resuscitation from cardiac arrest

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39 WHY?????

40 2010 AHA Changes FAQs Why did the CPR sequence change from A-B- C to C-A-B? 1 st, this change allows rescuers to begin chest compressions right away. As we know, most victims of sudden cardiac arrest (SCAs) receive no bystander CPR. Opening the airway is the most difficult and daunting task for the rescuer. The change attempts to decrease the barriers to performing CPR by allowing the rescuer to start with chest compressions. 2 nd, the vast majority of SCAs occur in adults who suffer a witnessed arrest & vfib or pulseless vtach. In these pts, the critical elements of CPR are chest compressions and early defibrillation.

41 FAQs Why do the 2010 Guidelines put so much emphasis on chest compressions? Compressions provide vital blood flow to the heart & brain during SCA, and research shows that delays or interruptions to compressions reduced survival rates. Ventilations are not as critical, as victims have O2 remaining in their lungs & bloodstream for the 1 st few minutes of an SCA. Starting CPR with chest compressions can pump that blood to the victim s brain & heart sooner. Compressions should be started ASAP, and interruptions in chest compressions should be minimized throughout the entire resuscitation period.

42 FAQs What are the key recommendations for healthcare professionals? Effective teamwork techniques should be learned & practiced regularly Professional rescuers should use quantitative waveform capnography the monitoring of CO2 output to confirm intubation & monitor CPR quality Therapeutic hypothermia, or cooling, should be part of an overall interdisciplinary system of care after resuscitation from cardiac arrest. Atropine is no longer recommended for routine use in managing & treating pulseless electrical activity (PEA) or asystole

43 References 2010 comparison charts. American Heart Association. AHA Advanced cardiovascular life AHA. Advanced cardiovascular life support: Provider manual