The following guidelines are an interpretation of the evidence presented in the 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Sponsoring Organization: American Heart Association (AHA) Target Population: Lay public, healthcare providers Background and Objective The AHA has released an evidence-based update to its 2010 guidelines for cardiopulmonary. 2010 American Heart Association Guidelines EMBARGOED FOR RELEASE for CPR and Emergency Cardiovascular Care Oct. EST Comparison Chart of Key Changes. HIGHLIGHTS of the 2015 American Heart Association Guidelines Update for CPR and ECC Heart and Stroke Foundation of Canada Edition. The New 2. 01. 0 CPR Guidelines and the MPDSOctober 2. It is truly exciting to see so much enthusiasm about the evolving clinical standards in our profession! This update is designed to keep you informed regarding the process of the Medical Priority Dispatch System. The Academy utilizes both a Standards Council made up of international DLS experts and a resuscitation sub- council consisting of renowned cardiopulmonary research physicians—who are dispatch oriented—to assist in the protocol’s evolution. These experts follow, and in many cases participate in, the research and evaluation that is the backbone of the International Liaison Committee on Resuscitation (ILCOR) Recommendations, published every five years by the AHA and the European Resuscitation Council (ERC). As such, the evolution of the MPDS is an ongoing process that does not depend on the formal issuance of new guidelines for change. In fact, you may have already noticed that most of the changes recommended by the new guidelines have already been implemented in the current version of the MPDS. Most importantly, you can be assured that your current version of the MPDS reflects the current DLS standard of care. The DLS Difference. The CPR and ECC guidelines published by the AHA are the result of an exhaustive evaluation of current research in related fields. These recommendations are provided specifically for laypersons, field responders (ALS and BLS), hospital providers, and—to a much more limited extent—emergency medical dispatchers. Because field and hospital medicine have relatively long histories, there is obviously more research available to ILCOR regarding these disciplines than there is in the field of DLS. Compression-Only CPR or Standard CPR in Out-of-Hospital Cardiac Arrest. Leif Svensson, M.D., Ph.D., Katarina Bohm, R.N., Ph.D., Maaret Castr 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care; ERC European Resuscitation Council; CPR: NHS Choices; How to resuscitate a child: NHS Choices; Sarver Heart Center. Resuscitation Guidelines for 2010 are out for the UK, Europe and the United States. We're still waiting for ours in Australia. Here is where to find the new guidelines and a few of the 'moves and shakes' are. Editorial Board 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science 2010 American Heart Association and American Red Cross Guidelines for First Aid. Accordingly, dispatch- specific recommendations are a relatively small portion of the published guidelines, although this fraction is increasing with each release. Fortunately, dispatch is formally being recognized as playing an integral and critical role in the patient care chain of survival, and the Academy is filling the gaps with regard to both dispatch research and the formulation of standards based on expert consensus and actual user input. DLS is a unique, non- visual practice utilizing trained EMDs following protocol. EMDs are not trained in the same methods as field responders; however, as they are specifically trained as medical professionals in the non- visual realm of emergency dispatch, they are certainly not laypersons. As such, DLS requires considerations not always included in layperson or professional recommendations, and may contain elements of both. This is why, on the surface, there seems to be pointed differences in what you may see in the guidelines for laypersons as compared to what you see in the MPDS. This may be best illustrated in the DLS recommendation to provide the head- tilt maneuver as a method of airway control versus the trained- rescuer recommendation to use the head- tilt/chin- lift maneuver, or even the recovery position. The unique, non- visual environment of DLS, the combination of trained EMD and untrained layperson, and the necessity of diligent, on- the- phone monitoring of critical patients demand these differences. Compressions 1st and Hands- Only CPRThe most prominent change in the new CPR guidelines is, undoubtedly, the move to a compressions first approach to the cardiac arrest victim (and where have we heard that term before?). Rather than providing an initial 2 breaths followed by 3. Instead of the familiar ABC (Airway, Breathing, Circulation) procedure, the recommendations now call for CAB (Circulation, Airway, Breathing). For the untrained rescuer, a Hands- Only approach is now recommended. As you may have noticed, this emphasis on compressions has been made in the MPDS since the release of the CPR Pathway Director in 2. While a 6. 00 Compressions 1st pathway is provided for victims of probable cardiac arrest, a 3. Ventilations 1st pathway is available for infants, children, and other patients with probable respiratory etiology. From the 2. 01. 0 Adult BLS Guidelines: Because rescue breathing is an important component for successful resuscitation from pediatric arrests (other than sudden, witnessed collapse of adolescents), from asphyxial cardiac arrests in both adults and children (e. CPR with rescue breathing is recommended for all trained rescuers (both in- hospital and out- of- hospital) for those specific situations (S6. What remains unclear, as pointed out by the new guidelines, is when, during the progression of cardiac arrest, the patient absolutely needs ventilations. Also from the new BLS guidelines: “However, at some time during prolonged CPR, supplementary oxygen with assisted ventilation is necessary. The precise interval for which the performance of Hands- Only CPR is acceptable is not known at this time” (S6. Because some EMS response times are unavoidably extended, and based on the best available research, the Academy’s Resuscitation Council set the Compressions 1st Pathway at 6. Essentially, this provides a Hands- Only sequence for most patients, but allows for eventual ventilations in cases with extended response times. In summary, the new guidelines suggest a Hands- Only approach to CPR for untrained rescuers during the first minutes of suspected cardiac arrest. These guidelines, however, remain unclear about when assisted ventilation is absolutely necessary and emphasize the importance of dispatch instructions: “If a bystander is not trained in CPR, then the bystander should provide Hands- Only (chest compression only) CPR, with an emphasis on “push hard and fast,” or follow the directions of the emergency medical dispatcher” (S6. These recommendations are currently incorporated into the MPDS (and have been since 2. Pediatrics and Asphyxial Arrest. If the arrest involves a child or infant, or is suspected to be asphyxial in nature, conventional CPR—with a 3. Hands- Only CPR is advised if the rescuer is untrained or unwilling to provide ventilations. This new recommendation (the reversed order of the conventional CPR procedure) is currently being considered for pediatrics and asphyxial arrest by the Academy’s Standards Council for implementation in the MPDS. However, it is important to note that the rationale for the order change in pediatrics and asphyxial arrest was not based on patient outcomes, but rather speed to compressions and ease of training. From the guidelines: It is, however, unknown whether it makes a difference if the sequence begins with ventilations (ABC) or with chest compressions (CAB). The CAB sequence for infants and children is recommended in order to simplify training with the hope that more victims of sudden cardiac arrest will receive bystander CPR. It offers the advantage of consistency in teaching rescuers, whether their patients are infants, children, or adults (S8. Currently, in arrests of probable respiratory origin, the order of operations instructions in the MPDS is the only variance from the new guidelines. However, the intention of the order outlined in the AHA guidelines is to simplify CPR training and enable the procedure to be easily remembered; this is not a problem in the DLS environment where a trained EMD is using a scripted protocol, providing exact instructions for the procedure. An Emphasis on Compressions. One clear message resounds from the new guidelines: start compressions early and avoid interruptions. The 2. 01. 0 guidelines address this issue in several ways. First, as mentioned above, a compressions first approach is now recommended for suspected cardiac arrest: “Beginning CPR with 3. S6. 88). Additionally, research has shown that the initial evaluation of a collapsed victim has led to compressions delays when gasping or agonal breathing has been mistaken for effective breathing. As a result, the new guidelines deemphasize checking for breathing and suggest that “CPR training, both formal classroom training and . This false- positive breathing phenomenon has been addressed in the MPDS through education involving agonal breathing and through the use of the Agonal Breathing Diagnostic Tool. Further efforts to reduce cardiac arrest detection time and eliminate compressions delays in the MPDS are ongoing and include modifications to the Check Airway and Check Breathing panels of the CPR sequence. Compression rate and quality is also in the spotlight of the new guidelines: Rescuer fatigue may lead to inadequate compression rates or depth. Significant fatigue and shallow compressions are common after 1 minute of CPR, although rescuers may not recognize that fatigue is present for 5 minutes. When 2 or more rescuers are available it is reasonable to switch chest compressors approximately every 2 minutes .. However, this option may become mandatory when a second rescuer is available, as the research shows fatigue and poor performance are not always recognized, and improper compression rate and quality clearly has an adverse effect on patient outcomes. Summary. The 2. 01. Guidelines for CPR emphasize rapid recognition of cardiac arrest by deemphasizing the breathing check and removing the old “Look, Listen, and Feel” method from the BLS algorithm. The current version of the MPDS adheres to these guidelines, as will future versions: the MPDS certification course teaches EMDs to recognize agonal breathing (gasping), the Agonal Breathing Diagnostic Tool provides real- time EMD support, and changes to the airway and breathing panels in MPDS v. The new guidelines recommend a Hands- Only approach for untrained rescuers when presented with an adult victim of suspected cardiac arrest, but recognize the need for ventilations at some point in the rescue effort. The MPDS provides a Compressions 1st pathway for these patients that delivers a Hands- Only CPR process for approximately 1. For the trained rescuer, the new guidelines recommend providing a 3. The current MPDS Pathway Director provides a 3. Ventilations 1st pathway in pediatrics, cases of suspected respiratory origin, or asphyxiation.
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