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
2010 Guidelines
• ABC
• CAB
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• Chest Compressions
• Airway
• Breathing
Airway
Breathing
Circulation
Compressions
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
2010 Guidelines
least 100/ minute-stay
– Approximately 100 per minute – At
tuned for what the upper
limit maybe
– Mid-nipple line
– Center of sternum
– ½-1/3 the depth of the chestinfant/child
– Recoil of chest discussed
– Keep interruptions < 10
seconds
– Change compressors q 2
minutes
– 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
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Adult
Unresponsive
No breathing
Agonal breathing
– Funny breathing
• No breathing
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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
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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
Breathing
with a pulse
Adult 2005 Guidelines
• Rescue breathing every 5
seconds
Adult 2010 Guidelines
• Rescue breathing every
5-6 seconds
• Children/infants every 3-5
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
2010 Guidelines
• Anterior-lateral position
– Only correct placement in
PALS
• Implantable
defibrillator/pacemaker
– Place pad at least 1”
away from device
• 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
• 2010 guidelines
• Vagal maneuvers
• Adenosine
• Synchronized cardiovert
• Vagal maneuvers
– Ice to face
– Straw
– Carotid massage-older child
• Adenosine
• Synchronized cardiovert
0.5-1 J/kg
2 J/kg
• Drugs-expert consolation
before administration
– Amiodorone
– Procainamide
Stable Ventricular Tachycardia
(V Tach)
2005 Guidelines
• Not enough evidence for
a recommendation
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•
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 Guidelines
Defibrillation dose
• 1st dose 2 joules/kilogram
• 2nd and subsequent dose
– 4 joules/kilogram
2010 Guidelines
Defibrillation dose
• 1st dose 2-4 joules/kilogram
– Teach 2 J/kg
• 2nd dose 4-10
joules/kilogram
– Teach then go to 4J/kg
• Wide complex >.08
• Hypothermia s/p
resuscitation d/t cardiac
cause maybe helpful
– 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
ET Tube
• Formulas now for both cuffed and
uncuffed
• 4+age/4 uncuffed
• 3.5+age/4 uncuffed
In-Hospital Death Between Hyperoxia and Normoxia
Kilgannon, J. H. et al. JAMA 2010;303:2165-2171.
Copyright restrictions may apply.
PALS
2005 Guidelines
• Calcium can be used in
arrest situation
2010 Guidelines
• Calcium administration in
cardiac arrest may have
benefit
– Known hypocalcemia
– Known calcium channel
blocker overdose
– Hyper magnesia/kalemia
• Etomidate-minimal
hypotensive effect with
RSI
• Etomidate should not be
used in suspected shock
Ethical Issues
• DNAR-Do Not Attempt Resuscitation
– Does not preclude
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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 PICU
15:2
NRP
2005 Guidelines
• 3:1 CPR
2010 Guidelines
• 3:1-unless arrest felt to
be cardiac in nature then
– 15:2 two rescuer
– 30:2 one rescuer
• Therapeutic hypothermia
is an area where
research is needed
• ≥ 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
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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
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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
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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) 21652171.
Contact Information
• Karen Manor RN, CEN, CPEN
• Karen.J.Manor@HealthPartners.com
• 651-254-7782