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American Heart Association BLS/ACLS/PALS Update Janet Smith

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Forget everything you know

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Instructor Goals Incorporate the previous changes from 2001 & present 2005 revisions Less number of algorithms Review Acute Pulmonary Edema, Hypotension, & Shock combined algorithms, & Hypothermia algorithm Stroke algorithm less busy & ACS not much change

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February 24, 2006 - Rollout First session BLS changes Second session ACLS & PALS update Begin new test revised 2005 Handbook of Emergency Cardiovascular Care includes Guidelines CPR/ECC 2005. Nice addition cardiac markers, Treatment w/ Non-ST-segment Elevation MI

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Instructor Objectives Fit the course to your needs Adult learners need positive reinforcement & deal well with scenarios Understand the exam (new & improved) What is your environment

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Student Objectives Discuss new basic life support guidelines Discuss patient assessment & survey Discuss the use of ACLS drugs Stations: Determine competency Discuss the ethical considerations in resuscitation

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What type of course do you need? Recertification versus full course Utilize your study guides or cheat sheets Review pretest written exam Provide scenarios

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ACLS goals Emphasis on trained & equipped Health Care Professional (HCP), but only in conjunction with trained lay rescuer & reduce time to CPR and shock delivery & obtain ultimate success Effective ACLS begins with high-quality CPR

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Drug changes 2005 Most drug doses are the same as those recommended in 2000 except use Atropine 0.5 mg IV for Bradycardia. May repeat to a total of 3 mg. Epinephrine or dopamine may be administered while waiting for a pacemaker

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Early intervention & effective CPR

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5 major changes 2005 guidelines Emphasis on, & recommendations to improve, delivery of effective chest compressions A single compression-to-ventilation ratio for all single rescuers for all victims (except newborns)

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5 major changes 2005 guidelines Recommendation that each rescue breath be given over 1 second & should produce visible chest rise A new recommendation that single shock, followed by immediate CPR, be used to attempt defibrillation for VF cardiac arrest. Rhythm checks should be performed every 2 minutes

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5 major changes 2005 guidelines Endorsement of the 2003 ILCOR recommendations for use of AEDs in children 1 to 8 years old (and older); use a child dose-reduction system if available

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5 major changes continued: AED teaching point Some AEDs have shown to be very accurate in recognizing pediatric shockable rhythms & may be used with regular adult pads

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Age Definition Child CPR guidelines apply to victims 1 year to the onset of puberty (about 12 14 years old) Chest compressions are recommended if the heart rate is less than 60 per minute with signs of poor perfusion

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Effective chest compressions push hard & push fast & chest compress the chest @ a rate of about 100 per minute (except newborns) Use 1 or 2 hands with a child (Use technique that gives best results) Allow the chest to recoil Limit interruptions in chest compression

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Effective chest compressions Chest compressions create a small amount of blood flow to vital organs the better the chest compressions (adequate rate, depth, & allowing for recoil) the more blood flow is produced

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Copyright 1996 American Heart Association Idris, A. H. et al. Circulation 1996;94:2324-2336 Arterial and central venous pressure waveforms during external closed chest compression

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Universal Compression-to- Ventilation all lone rescuers One universal compression-to- ventilation ratio for all lone rescuers: Single compression to ventilation ration of 30:2 for single rescuers of victims of all ages Teaching point: Simplify CPR & increase blood flow to the heart

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1-Second breaths during all CPR All breaths should be given over 1 second w/ significant volume to achieve visible chest rise Teaching point: During CPR, blood flow to the lungs is much less than normal, so the victim needs less ventilation than normal

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Review of BLS guidelines Determine if you require BLS proof prior to your course

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Basic Life Support Teaching concepts Early bystander CPR can double or triple the victims survival from VF & Sudden cardiac arrest (SCA) CPR plus defibrillator within 3 5 minutes of collapse can produce survival rates as high as 49% to 75%

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Basic Life Support Calling for help Lone Healthcare provider: Sudden collapse Phone 911 & get an AED available & then return to victim to begin CPR Unresponsive victim w/ likely drowning deliver about 5 cycles (about 2 minutes) of CPR prior to phoning 911 to get the AED & then return to CPR

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Lone Healthcare Provider/CPR Scenario: Patient unresponsive & non- breathing the Lone Healthcare provider will give 2 rescue breaths & then feel a pulse for no more than 10 seconds. If no pulse begin compression Adult: 30:2 Child: 15:2 (two rescuers)

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HCP- Rescue breathing Deliver rescue breath over 1 second Rescue breathing for a victim w/pulse Adult: 10 to 12 breaths/minute Infant/child: 12 to 20 breaths/minute Teaching point: Less ventilation than normal & not as effective as compressions

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Chest compressions components Adult: Center chest & @ nipple line & 1 to 2 inches using heel of both hands & lower half of sternum Child: 1/3 to depth of chest & using heel of one hand Rate: 100 on all patients

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HCP Chest compressions Compression during CPR & NO advanced airway is present: Deliver cycles of compressions 30:2 Compression during CPR & advanced airway IS present: No longer use cycles or pausing for rescue breathing. Deliver 100 compressions/minute w/ 8- 10 breaths/minute

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Lay Rescuers CPR may include information with your course Lay rescuers should immediately begin cycles of chest compressions after delivering 2 rescue breaths in the unresponsive victim. Lay rescuers are not taught to assess for pulse or sings or circulation Research notes that the lay public has a difficult time locating the correct place for palpation

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Defibrillation One shock followed by immediate CPR beginning w/ chest compressions & 5 cycles or 2 minutes Monophasic: 360 J Biphasic: 150 to 200 J

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AED Review Use the model for teaching & state the proper order - 4-Universal steps: Power AED Attach to victim Analyze rhythm Deliver shock if indicated

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Use of the AED Use adult pads on adults Use AED after 5 cycles of CPR (out of hospital) No recommendation for infants < 1 year of age Children 1 to 8 Use an AED with pediatric dose-attenuator

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Electrical Therapies Defibrillation involves delivery of current through the chest & to the heart to depolarize myocardial cells & eliminate VF Monophasic Deliver current to one polarity & higher energy level Biphasic Lower energy & are more in current use

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Management of Pulseless Arrest 5 cycles or 2 minutes or uninterrupted CPR & should resume immediately after deliver 1 shock Pulse & rhythm are NOT checked after shock

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Management of cardiac arrest Drug administration is of 2 nd importance NO IV access: Lidocaine, epinephrine, atropine, narcan, & vasopression are absorbed via the trachea w/typical dose 2 to 2 times the recommended IV dose & should dilute with water or NS Administer drugs during CPR

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HCP- Rescue breathing Deliver rescue breath over 1 second Rescue breathing for a victim w/pulse Adult: 10 to 12 breaths/minute Infant/child: 12 to 20 breaths/minute Teaching point: Less ventilation than normal & not as effective as compressions

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Airway management - review & observe student performance Demonstrate the BVM Intubation techniques Secondary confirmation techniques Securing the ETT C-Spine precautions & trauma 5-point chest exam

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Airway & C-spine management Use head tilt-chin lift technique to open the airway of trauma victim unless cervical spine injury is suspected Teaching point: Jaw thrust is a difficult maneuver & may not be an effective way to open the airway

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Airway station Use BVM Anyone providing prehospital care for adult, children, or infants should be trained to deliver effective oxygenation & ventilation The use of BVM should be considered to be the primary method of venilatory support, especially if t