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					Understanding the 2010 CPR/ECC
and First Aid Guidelines


David C. Berry, PhD, LAT, ATC
Associate Professor and Athletic Training Program Director
Department of Kinesiology
Saginaw Valley State University
University Center, MI
Objective

• Examine the 2010 CPR, Emergency Cardiac
  Care (ECC) and First Aid treatment guidelines
  and recommendations and the rational and
  science behind these suggested changes.
International Liaison Committee on
Resuscitation (ILCOR)
Representatives1

                                                                           Resuscitation Council of Asia
 Heart and Stroke Foundation of Canada
                                         European Resuscitation Council

      American Heart Association



        InterAmerican Heart Foundation




                                                                                                 Australian/New Zealand
                                               Resuscitation Council of Southern Africa
                                                                                                 Committee on
                                                                                                 Resuscitation
CPR-ECC Review Process

            1. Development of specific task force(s) (e.g., basic life support (BLS)).



        2. Identification of topics requiring an evidence evaluation by the task force(s).



  3. Formulation of hypothesis on these topics and appointment of international experts as
                          worksheet authors for each hypothesis.


4. Worksheet authors goals: (1) search for and critically evaluate evidence on the hypothesis, (2)
         summarize the evidence review, and (3) draft treatment recommendations.1


 5. The evidence is then presented, discussed, and debated, with task forces and resuscitation
                          councils meeting daily to draft summaries.


6. The Consensus on CPR and ECC Science and Treatment Recommendations (CoSTR) is then
            developed and published simultaneously in Circulation and Resuscitation.
CPR-ECC Review Process

• Individual organizations draft their specific
  guidelines for their population served,
  remembering to clarifying the most important
  skills needed to perform in an emergency
  situation to improve patient outcomes.
First Aid Review Process

• National First Aid Science Advisory Board
  (Co-founded by the AHA and ARC) reviewed
  and evaluated the scientific literature regarding
  first aid treatment guidelines.2

• Similar process to CPR-ECC guidelines;
  however, this review was the most compressive
  review ever completed looking to answer ……
First Aid Review Process
  Lay Rescuer CPR/ECC Key
Recommendations and Guidelines
Chain of Survival3
Chain of Survival
Post-Cardiac Arrest Care

• Designed to emphasize protocols for optimizing
  cardiovascular and neurological function to improve
  survival of victims with resumption of spontaneous
  circulation (ROSC) after cardiac arrest.1
• Includes-
   – Optimizing cardiopulmonary function/vital organ perfusion after
     ROSC.
   – Transporting to an appropriate hospital/critical care unit with a
     comprehensive post–cardiac arrest treatment system.
   – Identify and treat ACS and other reversible causes.
   – Control temperature to optimize neurologic recovery
   – Anticipate, treat, and prevent multiple organ dysfunction. This
     includes avoiding excessive ventilation and hyperoxia.
Simplified ILCOR Universal Adult
BLS Algorithm1
Simplified Universal Adult BLS
Algorithm4

                     American Heart Association
Emphasis on Chest Compressions

                   New for 2010
• Bystanders NOT trained in CPR should provide
  Hands-Only™ (compression-only) CPR for the
  adult patient who suddenly collapses, with an
  emphasis to “Push Hard and Fast” on the
  center of the chest.

• Continue Hands-Only™ CPR until-
   1. AED arrives and is ready for use or
   2. EMS or another responder(s) takes over care.
Emphasis on Chest Compressions

                  Why Change?
• Compression-only bystander CPR has been
  shown to substantially improve survival
  following adult out-of-hospital cardiac arrests
  compared with NO bystander CPR.5-8
Emphasis on Chest Compressions

   How can bystander CPR be effective without
                     rescue breathing?

• During SCA (with VF), rescue breaths initially are not as
  important as chest compressions because the oxygen
  level in the blood remains adequate for the first several
  minutes after cardiac arrest.4

• Animal models suggest gasping or agonal gasps do allow
  for some oxygenation and carbon dioxide
  (CO2)elimination.9-10
“C-A-B” rather than “A-B-C”

     New for 2010            Why Change?
• Initiate chest        • Beginning CPR with 30
  compressions before     compressions rather than
  ventilations.           2 ventilations leads to a
                          shorter delay to first
                          compression11-13
                          providing vital blood
                          flow to the heart and
                          brain.
Elimination of “Look, Listen, and
Feel”
      New for 2010                  Why Change?
• “Look, listen, and feel”     • With the new “chest
  was removed from the           compressions first”
  CPR sequence.                  sequence, CPR is
                                 performed if the adult is
• After delivery of 30 chest     unresponsive and not
  compressions, the lone         breathing or not
  rescuer will open the          breathing normally.3
  airway and deliver 2         • Look, Listen and Feeling
  breaths, each for 1            is also inconsistent and
  second.                        time consuming.
Chest Compression Rate
“At Least 100 per Minute”

     New for 2010                  Why Change?
• Reasonable for lay          • More adequate chest
  rescuers to perform chest     compressions per minute
  compressions at a rate of     was associated with
  at least100                   higher survival rates
  compression/min.            • Fewer compressions
                                were associated with
                                lower survival rates.14-15
Chest Compression Depth

     New for 2010                 Why Change?
• Adult and child sternum    • Science suggests that
  should be depressed at       compressions of at least 2
  least 2 inches (5 cm).       inches was more effective
• Infant sternum should be     than compressions of 1
  depressed at least 1 ½       ½ inches.16-18
  inches (4 cm).
                             • Believed confusion exists
                               when a depth range is
                               recommended, so 1
                               compression depth is
                               now recommended for
                               all ages.
 Healthcare Provider CPR/ECC
Recommendations and Guidelines
Healthcare Provider Adult BLS
Algorithm4
Emphasis on Chest Compressions

      New for 2010                  Why Change?
• Effective chest              • Healthcare providers
  compressions are               should be trained to
  emphasized, but                perform both
  optimally all healthcare       compressions and
  providers should be            ventilations.3
  trained in BLS, thus it is   • If healthcare providers
  reasonable to provide          are unable to perform
  chest compressions and         ventilations, the provider
  rescue breaths for cardiac     should activate the
  arrest victims.                emergency response
                                 system and provide
                                 chest-only compressions.
Activation of Emergency Response
System
     New for 2010                  Why Change?
• Healthcare providers        • Healthcare providers
  should check for              should not delay
  response while looking at     activation of the
  the patient to determine      emergency response
  if breathing is absent or     system but should obtain
  not normal.                   2 pieces of information
                                simultaneously:
                                 1. Responsiveness
                                 2. No breathing or no
                                    normal breathing.4
Cricoid Pressure

      New for 2010                    Why Change?
• The routine use of             • RCTs demonstrated
  cricoid pressure for             cricoid pressure delayed
  patient of cardiac arrest is     or prevented placement of
  NOT recommended.                 an advanced airway and
                                   that aspiration may occur
                                   even with application of
                                   pressure.26-29
                                 • Manikin studies30-32 found
                                   the maneuver difficult for
                                   both expert and
                                   nonexpert rescuers.
Healthcare Provider and Lay Rescuer
Consistent Adult Changes
• Change in CPR Sequence-
  – C-A-B Rather Than A-B-C
• Chest Compression Depth
  – Adult sternum should be depressed at least 2
    inches (5 cm).
• Chest Compression Rate
  – At Least 100/minute
Key BLS Components for Adult,
Children, and Infants3
Key BLS Components for Adult,
Children, and Infants3
Electric Therapies
Adult

• The 2010 International Consensus on Science
  With Treatment Recommendations statement
  contains no major differences or dramatic
  changes for adult defibrillation compared to the
  2005 International Consensus statement.33
Electric Therapies
Pediatric

      New for 2010                     Why Change?
• A pediatric dose-               • AEDs with relatively
  attenuator AED should             high-energy doses (as
  be used for children ages         high as 9 J/kg) have been
  1-to-8.                           used successfully for
• For infants (<1 year of           infants in cardiac arrest
  age), a manual                    with no clear adverse
  defibrillator is preferred.       effects.34
• If neither unit is available,
  an AED without a dose
  attenuator may be used
  for both age groups.
Electric Therapies
Shock First vs. CPR First

                Reaffirmation 2010
• When SCA is witnessed and an AED IS immediately
  available, rescuers should start CPR with chest
  compressions and use the AED as soon as possible.

• When SCA is not witnessed initiate CPR while checking
  and preparing for defibrillation.

• Whenever 2 or more rescuers are present, CPR should
  be provided while the defibrillator is retrieved.3
Electric Therapies
Electrode Placement

      New for 2010                      Why Change?
• The anterior-lateral pad         • Studies suggest that all 4
  position is the default            AED pad placements
  electrode placement                were equally effective in
  when using an AED.                 defibrillation for VF.35-38
• However, any of 3
  alternative pad positions
  may be used-
   – Anterior-posterior
   – Anterior–left infrascapular
   – Anterior–right
     infrascapular
First Aid Recommendations and
           Guidelines
 Supplemental (Emergency) Oxygen

No Change From 2005                  Why Change?
• Administration of oxygen      • No benefit of
  is not recommended for          supplementary oxygen
  patients with shortness of      administration was found
  breath or chest                 in treating patients with
  discomfort.                     shortness of breath or
      New for 2010                chest discomfort.39-41
• Supplementary oxygen          • Evidence that
  administration should be        supplementary oxygen
  considered as part of first     for divers with
  aid for divers with a           decompression injury
  decompression injury.           may be effective.42
 Epinephrine and Anaphylaxis

      New for 2010                   Why Change?
• Recommended that if the       • Approximately 18% to
  symptoms of anaphylaxis         35% of patients
  persist despite                 presenting with signs and
  administration of an Epi-       symptoms of anaphylaxis
  pen, rescuers should seek       may require a 2nd dose of
  medical assistance before       epinephrine,43-45 however
  administering a 2nd dose of     the diagnosis of
  epinephrine.                    anaphylaxis can be a
                                  challenging and excessive
                                  epinephrine
                                  administration may
                                  produce complications.2
 Aspirin Administration for Chest
 Discomfort
      New for 2010                        Why Change
• Rescuers should advise the        • Aspirin is beneficial when
  patient to chew 1 adult             chest discomfort is due
  (non-coated) or 2 lowdose           to an acute coronary
  “baby” aspirins if the              syndrome (ACS),
  patient has-                        however, the
   – No allergy to or other           administration of aspirin
   – Contraindications to aspirin     must never delay EMS
     (e.g., stroke or recent          activation.2
     bleeding).46-48
Bleeding Control
Tourniquets

               No Change From 2005
• The use of a tourniquet to control bleeding of the
  extremities is indicated ONLY IF direct pressure is
  NOT effective or possible and if the provider has
  PROPERLY trained in tourniquet use.
Bleeding Control
Hemostatic Agents

                     New for 2010
• The routine use of hemostatic agents to control bleeding
  as a first aid measure is NOT recommended at this time
  for lay responders, but may be considered if direct
  pressure and tourniquets are not possible for
  professional rescuers.2
Bleeding Control
Pressure Points and Elevation

                  Reaffirmation
• Elevation and pressure points are not
  recommended to control bleeding.2

                   Why Change?
• This recommendation is made because there is
  evidence that other methods of controlling
  bleeding are more effective2 and as of 2010 no
  studies had examined the hemostatic effects of
  elevation to control bleeding.
Bleeding Control
Shock

                   New for 2010
• If a victim shows evidence of shock, have the
  victim lie supine, DO NOT elevate the feet.

                   Why Change?
• Simplified decision-making.
• There are no studies examining the effects of leg
  position (elevation) as a first aid maneuver for
  the management of shock.2
Animal Bites
Snakebites

     New for 2010                        Why Change
• Care of any venomous              • Effectiveness of pressure
  snake bite is now                   immobilization has been
  consistent.                         shown to be effective and
   – Place a pressure bandage         safe in slowing lymph
     around the length of the         flow and the
     bitten extremity with            dissemination of snake
     pressure applied between-
       • 40-70 mm Hg in the upper
                                      venom.49-51
         extremity
       • 55-70 mm Hg in the lower
         extremity
 Animal Bites
 Jellyfish

      New for 2010                  Why Change?
• To inactivate venom and      • Evidence suggests that
  prevent further                vinegar is most effective
  envenomation, stings           solution for inactivation
  should be liberally washed     of the nematocysts. 52-55
  with vinegar (4-6% acetic    • Immersion with water, as
  acid solution) quickly and     hot as tolerated for about
  for at least 30 secs.          20 minutes, is most
• Once nematocysts are           effective for treating the
  removed/deactivated, the       pain.52-55
  pain should be treated
  with hot-water immersion.
Environmental Emergencies
Heat Stroke

                    New for 2010
• The most important action to manage heat stroke is
  to begin immediate cooling, preferably by
  immersing the victim up to the chin in cold
  water.56-58
• It is also important to activate the EMS system as
  heat stroke requires emergency treatment with
  intravenous fluids.2
• Do not try to force the victim to drink liquids if they
  have altered mental status.2
Environmental Emergencies
Frostbite

                    New for 2010
• Better distinction between recognition and care for
  minor and severe frostbite.
   – Care - minor
      • Skin-to-skin contact
   – Care – severe
      • Rewarmed by immersing extremity in warm (98.6° to
        104°F or approximately body temperature) water for
        20 to 30 minutes.2
• Chemical warmers should not be placed directly on
  frostbitten tissue because they can reach
  temperatures that can cause burns.59
Spinal Stabilization

                    New for 2010
• Maintain spinal motion restriction by manually
  stabilizing the head so that the motion of head, neck,
  and spine is minimized.2

• Providers should not use immobilization devices
  because their benefit in first aid has not been
  completely proven and they may be harmful.2

• However, if needed, providers should be properly
  trained in their use.2
Ingest Poisons
Treatment With Milk or Water

                   New for 2010
• There is insufficient evidence to show that milk
  or water dilution of ingested poisons produces
  any benefit as a first aid measure.2

• Possible adverse effects of water or milk
  administration include emesis and aspiration.
Ingest Poisons
Activated Charcoal and Ipecac

• Do Not administer activated charcoal to a patient
  ingesting a poisonous substance unless advised by
  poison control center or emergency medical
  personnel.2
   – Activated charcoal is safe to administer60-61 but no
     evidence to suggest that it is effective as a component
     of first aid.

• Do Not administer syrup of ipecac for ingestions of
  toxins as there is no advantage to administering
  syrup of ipecac and it may delay care in an advanced
  medical facility.
     References

1.    Nolan JP, et al. Part 1: Executive summary 2010 International Consensus on
      Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With
      Treatment Recommendations. Resuscitation. 2010;81S:e1-e25. Available at:
      http://www.cprguidelines.eu/2010/costr.php.
2.    Markenson D, et al. Part 17: First Aid: 2010 American Heart Association and American
      Red Cross. Circulation. 2010;122;S934-S946. Available at:
      http://circ.ahajournals.org/cgi/content/full/122/21/2228.
3.    American Heart Association. Highlights of the 2010 American Heart Association
      Guidelines for CPR and ECC. Available at:
      http://static.heart.org/eccguidelines/index.html
4.    Swor RA, et al. Part 5: Adult Basic Life Support: 2010 American Heart Association
      Guidelines. Circulation. 2010;122;S685-S705. Available at:
      http://circ.ahajournals.org/cgi/content/full/122/18_suppl_3/S685.
5.    Sayre MR, et al. Hands-only (compression-only) cardiopulmonary resuscitation: a call to
      action for bystander response to adults who experience out-of-hospital sudden cardiac
      arrest: a science advisory for the public from the American Heart Association Emergency
      Cardiovascular Care Committee. Circulation. 2008;117:2162–2167.
6.    Ong ME, et al. Comparison of chest compression only and standard cardiopulmonary
      resuscitation for out-of-hospital cardiac arrest in Singapore. Resuscitation. 2008;78:119-126.
7.    Bohm K, et al. Survival is similar after standard treatment and chest compression only in
      out-of hospital bystander cardiopulmonary resuscitation. Circulation. 2007;116:2908-2912.
8.    Iwami T, et al. Effectiveness of bystander-initiated cardiac-only resuscitation for patients
      with out-of-hospital cardiac arrest. Circulation. 2007;116:2900-2907.
9.    Berg RA, et al. Assisted ventilation does not improve outcome in a porcine model of