2005 AHA GUIDELINES FOR CPR AND ECC

1. 2005 AHA GUIDELINES FOR CPR AND ECC

2. How Should we do it?

3. HISTORY 1956. External Defibrillation by Zoll Zoll PM. N Engl J med. 1956:254:727-732. 1958. Mouth-to-mouth ventilation by Safar Safar P. N Engl J Med. 1958:258:671-677. 1960. Closed chest compression by Kouwenhoven Kouwenhoven WB. JAMA. 1960;173:1064-1067. 1974. Standards for CPR and ECC 1997. In-Hospital Utstein Style

4. Utstein Abbey, NORWAY

5. UTSTEIN STYLE • 목적 : terminology, definition, data통일 • Out-of-hospital Utstein style 1991 • Pediatric Utstein style 1995 • In-hospital Utstein style 1997 • Major trauma Utstein style 1999

6. History of Guidelines • 1966, National Academy of sciences-National Research Council • 1974, Standards for CPR and ECC • 1980, Standards and guidelines for CPR and ECC • 1986, Standards and guidelines for CPR and ECC • 1992, Guidelines for CPR and ECC • 2000, Guidelines 2000 for CPR and Emergency Cardiovascular Care-An International Consensus on Science • 2005, 2005 AHA Guidelines for CPR and ECC

7. 2005 AHA Guidelines for CPR and ECC http://www.americanheart.org/downloadable/ heart/1132621842912Winter2005.pdf http://www.americanheart.org/eccguidelines http://www.eccguidelineswebcast.org

8. Contents • Part 1. Introduction • Part 2. Ethical Issues • Part 3. Overview of CPR • Part 4. Adult Basic Life Support • Part 5. Electrical Therapies: AED,Defibrillation,Cardioversion, Pacing • Part 6. CPR Techniques and Devices • Part 7. Advanced Cardiovascular Life Support • Part 8. Stabilization of the Patients With Acute Coronary Syndromes • Part 9. Adult Stroke • Part 10. Special Resuscitation Situations • Part 11. Pediatric Basic Life Support • Part 12. Pediatric Advanced Life Support • Part 13. Neonatal Resuscitation guidelines • Part 14. First Aid

9. Part 1. Introduction 1 • Design: improve survival from sudden cardiac arrest from acute life-threatening cardiopulmonary p. • Differ from previous guidelines 1. based on extensive evidence review 2. new structured and transparent process www.C2005.org 3. Reduce rescuer learn and remember, Clarify important skills

10. Levels of Evidence Introduction 2.

11. Classification of recommendation Introduction 3. Class Indeterminate. • Research just getting started • Continuing area of research • No recommendations until further research (eg, cannot recommend for or against)

12. 12 algorithms Introduction 4. • Box shape: square corners - intervention, therapy round corners - assessment color: rose - assessment blue - electrical therapy, drug tan - simple action green - A,B,C, blue shadow - narrow complex tachycardia yellow shadow – wide complex tachycardia

13. New developments Introduction 5. • 1. Simplify CPR instruction • 2. Increase number of chest compressions • 3. Reduce interruptions in chest compression

14. Overview of CPR 1. • Epidemiology(in U.S.A.) 250,000 death in OOH • To be successful CPR Start as soon as collapse Training / willing public to initiate CPR Call for professional help / AED

15. “Chain of Survival” 27.4 min 5.2% 5.0% 10.3 % • Early recognition of the emergency , activation of the emergency medical services (EMS) • Early bystander CPR • Early delivery of defibrillator • Early advanced life support , postresuscitation care (healthcare providers)

16. Adult BLS Sequence

17. Adult BLS Sequence

18. Open the Airway • Head tilt– chin lift maneuver Lay Rescuer:both injured and noninjured victims(Class IIa) Healthcare Provider: without evidence of head/neck trauma • Jaw thrust Lay Rescuer:no longer recommended : difficult for lay rescuers, not an effective way to open the airway, cause spinal movement cervical spine Healthcare Provider: cervical spine injury (Class IIb)

19. Check Breathing • look, listen, and feel • Lay rescuer : detect normalbreathing Healthcare provider :detect adequatebreathing within 10 seconds • lay rescuer : unwilling or unable to give rescue breaths - chest compressions (Class IIa) • occasional gasps as if he or she is not breathing (Class I) : give rescue breathing

20. Ventilation 1) each rescue breath over 1 second (Class IIa) 2) sufficient tidal volume to visible chest rise(Class IIa) 3) avoid rapid or forceful breaths 4) advanced airway is in place during 2- person CPR - ventilate at a rate of 8 to 10 breaths/minute - tidal volumes : 500 to 600 mL (6 to 7 mL/kg) (Class IIa) - no pause in chest compressions for ventilations (Class IIa)

21. Pulse Check (for Healthcare Providers) • lay rescuers – not recommend(2000) : checking for breathing, coughing, or movementis not superior for detection of circulation (2005) • healthcare provider : should take no more than 10 seconds to check for a pulse (Class IIa)

22. Chest Compressions • “Effective” chest compressions are essential for providing blood flow during CPR (Class I) • “push hard and push fast.” - adult chest at a rate of about 100 comp./min - compression depth of 1.1⁄2 to 2 inches (approximately 4 to 5 cm) ▪ recoil completely after each compression - equal compression and relaxation times • Minimize interruptions in chest compressions -checking the pulse, analyzing rhythm, or performing other activities (Class IIa) ▪switch the compressor about every 2 min.

23. Compression-Ventilation Ratio • compression-ventilation ratio - 30:2 • In infants and children, 2 rescuers - 15 : 2(Class IIb) - increase number of compressions - reduce hyperventilation - minimize interruptions - simplify instruction for teaching and skills ▪advanced airway is in place - 2 rescuers no longer deliver cycles of CPR - compressing rescuer continuous compressions 100 per minute without pauses - ventilation 8 to 10 breaths per minute

24. Compression-ventilation ratio

26. Defibrillation • Immediate defibrillation : TOC for VF of short duration, such as witnessed SCA (Class I) 1) adult out-of-hospital cardiac arrest that is not witnessed : give a period of CPR (5 cycles) before checking the rhythm and attempting defibrillation (Class IIb) 2) In settings with lay rescuer AED programs , in-hospital environments or EMS rescuer witnesses the collapse : defibrillator as soon as available(Class IIa)

27. Part 5. Electrical Therapies: AED,Defibrillation,Cardioversion, Pacing • Two critical questions integration of CPR with defib. • CPR should be provided before defibrillation? • Number of shocks? • Shock First VS CPR First • OH witnessed arrest : CPR and defibrillation as soon as possible! • OH unwitnessed arrest : 5 cycle CPR → Check ECG rhythm and attempt defibrillation!  (Class llb) • CPR before defibrillation for in hospital cardiac arrest : no data

28. 1-Shock VS 3-Shock • 1-Shock Protocol VS 3-Shock Sequence • No published human or animal studies • Benefit of another shock < harmful effects from interruptions to chest compression • In animal studies : interruptions compressions → postresuscitation myocardial dysFx & survival rate↓ • 2nd analyses of 2 randomized trials : interruptions compressions → probability of defibrillation ↓ • 2 recent clinical observational studies : compressions only 51~76% of total CPR time. • AED : first shock and first post-shock compression → up to 37sec

29. Defibrillation Waveforms and Energy Levels • Monophasic waveform defibrillators • Deliver current of one polarity • MDS (monophasic damped sinusoidal waveform) • Returns to zero gradually (common) • MTE (monophasic truncated exponential waveform) • Returns to zero abruptly

30. Biphasic Waveform Defibrillators • Research (Monophasic vs Biphasic) • indicates that lower-energy biphasic waveform(<200J) shocks equivalent or higher success for termination of VF than monophasic (Class IIa). • No direct comparison of different biphasic waveforms • Optimal energy for first-shock biphasic → not determined • Unknown • immediate outcomes (defibrillation) • short-term outcomes (ROSC, survival to hospital admission) • long-term outcomes (Survival to hospital discharge, survival for 1 year)

31. 3.Fixed and Escalating Energy • Fixed and Escalating Energy • Current research • Initial shock Rectilinear biphasic waveform : 120J Biphasic truncated exponential waveform : 150J~200J • Second and subsequent shocks, same or higher energy (Class IIa)

33. 3.AED (Automated External Defibrillators) • Electrode Placement • Pad position • Conventional sternal-apical (anterolateral) position (Class IIa). • Rt(sternal) : Rt Superior-Anterior (infraclavicular) chest, Lt(apical) : inferior-lateral left chest, lateral to the left breast (Class IIa). • Biaxillary ; Rt : lateral chest wall on the right, Lt : lateral chest wall on the left sides (Class IIa) • Rt : right or left upper back, Lt : standard apical position (Class IIa).

35. Electrode Placement • Electrode Placement • Implantable medical device is located in an area : 1 inch (2.5cm) away (Class Indeterminate). • ICD(delivering shocks) : allow 30~60 seconds for the ICD • Do not place AED electrode pads directly on top of a transdermal medication patch • Chest is covered water : wipe • AEDs can be used when the victim is lying on snow or ice. • Hairy chest : remove some hair

36. AED Use in Children • AED Use in Children • lowest energy, upper limit : not known. • Recommended manual defibrillation(monophasic or biphasic) doses • 2 J/kg for the first attempt (Class IIa) • 4 J/kg for subsequent attempts (Class Indeterminate) • 1~8 years : pediatric dose-attenuator system if available.if unavailable → use a standard AED! • AEDs 0~1 year (Class Indeterminate)

37. 10.Pacing • Not recommended for asystole (Class III). • Considered in symptomatic bradycardia. • Three randomized controlled trials • Pacing in asystolic patients in the prehospital or hospital • No improvement in the rate of admission to hospital or survival to hospital discharge • Transcutaneous pacing • Symptomatic bradycardia with pulse • Transvenous pacing • Not respond to transcutaneous pacing

38. Part 7.1:Adjuncts for Airway Control and Ventilation • Airway Adjuncts • Oropharyngeal Airways (Class IIa) • Nasopharyngeal Airways • Bag-Mask Ventilation • the rescuer should deliver a tidal volume sufficient to produce chest rise : approximately 6~7mL/kg(or 500~600mL) over 1 second. • During CPR, give 2 breaths during a brief(3~4sec) pause after every 30 chest compressions. • When an advanced airway replaces the face mask, rescuers should deliver 8 to 10 breaths per minute during CPR • Patient with perfusion rhythm : 10~12/min

39. Part 7.1:Adjuncts for Airway Control and Ventilation • Advanced Airways • Rescuers may defer insertion of an advanced airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb). • Once an advanced airway is in place, 2 rescuers no longer deliver cycles of CPR • Esophageal-Tracheal Combitube • Laryngeal Mask Airway (Class IIa). • Endotracheal Intubation

40. Scientific Basis of New Guideline 2005 • Ventilation during CPR • Shock first vs CPR first

41. Major Changes in the 2005 AHA Guideline Ventilation during CPR 1

42. Is Ventilation Necessary? 13 Swine, VF arrest model, 3 min untreated + 10 min BLS Compression only CPR Ventilation:Compression(2:30) CPR Dorph E, et al. Resuscitation 1999;27:1893-1899

43. Is Ventilation Necessary? 39 Swine, Pediatric asphyxial arrest model 24hr neurologically normal survival Berg RA, et al. Crit Care Med 1999;27:1893-1899

44. Tidal Volume

45. Vicious Cycle of Increasing Gastric Inflation (Unprotected Airway) Wenzel V, et al. Resuscitation 1998;38:113-118

46. Distribution of Gas between the Lung and Stomach during CPR(Unprotected Airway) • Patient’s lower esophageal sphincter pressure (LESP) • Patient’s respiratory mechanics (respiratory system compliance and degree of airway obstruction) • Technique of the rescuer performing BLS (inspiratory flow rate, peak airway pressure, and tidal volume)

47. Smaller Tidal Volume 80 patients undergoing anesthesia for routine surgery , 3min apnea, BMV with FiO2 0.5 Wenzel V, et al. Resuscitation 1999;43:25-29

48. Breath Delivery Interval

49. Quality of CPR (BLS training) 53 first-year medical student, Performance tests immediately and six months after training Heidenreich JW, et al. Resuscitation 2004;62:283-289

50. Adverse Hemodynamic Effects of Rescue Breathing 14 Swine, 3 min VF arrest model, Standard CPR, C:V=15:2 Berg RA, et al. Circulation 2001;104:2456-2470