Hi my name is Roy Shaw, licensed paramedic and lead instructor for procpr and the profirstaid programs
for protrainings. The highlights of the 2010 American Heart Association guidelines for CPR and ECC
have come up with some recommendations and updates now that we're in the new 2010 guideline phase. As
a health care professional, some of these may make sense to you and some may not make sense to you.
The whole purpose of my being here and explaining this to you, is to try and synthesize this down and
have it make sense. It's one thing to look at the science and to look at all the consensus and it's another
to try and get our heads wrapped around it as professional rescuers or as health care providers and
get behind it and believe in what we're doing and why we're doing it. My hopes are that I'll simplify
the things that are maybe a little complicated and that I'll shine some light on the things that may
seem ambiguous to you. Let's get started. In regards to the cardiac arrest victim that may be present
with a short period of seizure activity or agonal gasps, that may confuse potential rescuers, we're now
teaching dispatchers that they should be trained to identify the presentations of cardiac arrest
that started this way. Okay, so let me explain. There was confusion when people would call 911 and the
dispatcher would ask, is the person moving, are they breathing? And in reality, you know as well
as I do, when a cardiac arrest victim stops circulating oxygen to the brain, it's a shock and it
may cause a cardiac related seizure. Well, while they are seizing, they are in the tonic phase
it could be misinterpreted as still being alive and moving. So, they might tell the dispatcher, yeah,
the patient is moving. If they are in agonal respirations, which is extremely common, now get this, agonal
respirations are extremely common in the first minute or two of cardiac arrest, the bystander who
isn't trained, may interpret this as the patient is breathing. So now the dispatcher's information is
that the patient is moving and breathing. Do you think that there's a chance that they will
initiate CPR? Probably not, because the dispatcher cannot see the patient. So, based on that information
and based on the science we've gathered, we now know that because most cardiac arrest patients, when
they go into cardiac arrest with a bystander witnessing it, may be misinterpreted because we're not
asking the right questions. So, these new 2010 guidelines are basically trying to train dispatchers
how to ask the right questions, to be able to steer through the fog, in order to determine if the person
is in a seizure or agonal respirations, thereby, giving the dispatcher the correct information and
helping to tell the lay rescuer what to do next appropriately which in this case would be, start
CPR and we're going to activate an ambulance get them right out there. So that's the idea behind
the new information which is now out and released. It will be incorporated into the EMD classes so
that they get up to snuff and know what good and qualifying questions to ask call-ins in order to determine
what is actually happening on scene. Now, this next one is one of those pet peeves of mine, because I believe
that with good training like ProTrainings, we can go the extra mile and teach lay people how to
give good quality CPR Including rescue breathing with personal protective equipment. However,
I understand that there are a lot of people that would never take advantage of the education
for whatever reason they will not get trained proactively and thereby, will be reactive when responding
to an emergency. Because that is commonly the case, dispatchers are now being instructed to tell lay
rescuers who have never been trained before or who are not comfortable giving mouth to mouth resuscitation
without personal protective equipment, to provide hands only compressions cpr, what they're calling hands
only CPR, or compression only resuscitation for adults in sudden cardiac arrest.
Now, I've told you the reasons why they're doing that now, so as a healthcare professional
when you arrive on scene prehospital or you see a bystander do this out of hospital,
remember, if they're doing chest compressions fast and hard only, and not giving rescue breaths,
that's what they've been told to do. So be aware of that. The good news is, there is some decent
science, limited as it may be, that is showing on pig, dog and some human models, that fast, deep compressions
in the first few minutes of cardiac arrest is helping to stabilize the patient hemodynamically.
Thereby, buying time, and saving brain and heart cells. So, let's think positively on this, and that's
why we'll see bystanders doing hands only CPR. Alright, some changes have been made to the
immediate recognition of no breathing or no normal breathing. Now, no normal breathing to a health
care provider means, agonal respirations. The gasping type of trying to take a breath,
the medulla oblongata, the brain stem activity which is last to die, when oxygen has been held back from
the brain and yet still gives the autonomic nervous system response to try and take a breath diaphragmatically but
doesn't have the tone quality or the strength to complete it. That is not breathing.
You know that, I know that, that does not qualify as breathing but it may be misinterpreted as breathing
to a lay rescuer. So, when we as health care professionals see agonal respirations, or no respirations
we're activating the code team or calling for emergency response right away. If that has taken place
and we've already activated the emergency response system, to retrieve an AED or we've sent
someone to do that, we are no longer taking more than 10 seconds to check for a carotid pulse.
Now catch this, because it can be difficult to determine whether an unresponsive, non breathing
patient, has a pulse, a weak pulse, a thready pulse or has an irregular pulse, if we can't
easily identify a definite pulse within 10 seconds and the patient is not breathing normally or moving
they get CPR period. So, no more extended time checking for pulses or pulse quality.
Check for no longer than 10 seconds and if it's not definite that you've found a pulse and
the patient is not breathing and not responsive...CPR. Okay? So, that's the emphasis for 2010
guidelines. Now check this out. Look, listen and feel...gone! For 2010, we are no longer
doing the head tilt, chin lift, look, listen and feel. The montra we've trained with forever,
is gone. I don't really know why it's gone. It's not a difficult skill in my opinion, in fact
it's one of the easier ones. In fact, I could have seen throwing out pulse checks before I could have
seen throwing out the look, listen and feel and no breathing. That's my opinion, however, maybe it saves
a little time. Maybe...Yeah. I don't know why they changed it, but they did. So, no longer look
listen and feel, we're just going to say if they're not breathing and they're not moving and we
can't feel a pulse...CPR. Chest compressions right away. The emphasis has been placed on the
high quality of the CPR which I believe is a good thing. The compressions are going to be fast,
they are going to be deep, we're going to allow for full recoil of the chest. We're not bouncing our
hands off the chest, but we're fully recoiling on the chest before we perform another compression.
And we're going to minimize interruptions. So, we're still giving 30 compressions to 2 rescue
breaths, but we're going to minimize the amount of time between giving the breaths and getting
right to chest compressions. The other major change is that we're doing chest compressions
first and then giving the two rescue breaths. So different than the airway, breathing, circulation
open the airway, give two breaths, check a pulse...no more. Not breathing normally, can't feel pulse,
right into chest compressions. 30 chest compressions deep and fast and then two full rescue breaths.
To get chest rise and fall. This high quality chest compression, high rate with full recoil,
is being shown through studies to increase intrathoracic pressures, as well as increase
circulatory percentages, which adds to better hemodynamics and ideally, better recovery and
better quality of life after resuscitation. That's what the science is pointing towards
that's why it's been implemented. So, good news in that area. Remember back when it was around 100
times per minute? Now, looking at the high quality chest compressions, it's at least 100 times per minute.
So, If I wanted to be kind of "bunk" about it, you could say, "well you don't want to go
160 times per minute!" No, that's true, but it's a pretty big stretch to think that we could do 160
compressions per minute. I don't think we have to worry about that. And if we're doing 120
compressions in a minute, that's what our heart rate is at if you're excited or exercising moderately.
So even that is not supraventricular tachycardia or ventricular tachycardia. So, it's going to be at
least 100 beats per minute or even a bit faster. In order to get pulse pressures up and increase
circulatory percentages. That's the idea behind it. And, we used to say between 1 and 1/2 and 2 inches
deep, now at least 2 inches deep. The pattern is that we're not compressing deep or fast enough.
It's not that we're doing to much. That's why the emphasis has come back. When it comes to
children and infants, we're going at least a third of the depth of the chest. You with me now?
Instead of 1/2 inch to 1 inch for infant 1 to 1 and 1/2 for a child, now we're doing
one third and that's it. It doesn't matter what the age of the patient is, we're going a third of the
depth of the chest. On an infant and a child. Again, trying to get full, deep, fast compressions
to get circulation up. Now, here's an interesting one. In some of your regions you haven't been
doing this anyway. That's the rule here for me. Cricoid pressure during ventilations is no longer
recommended. I don't think it's been recommended for some time in my region.
Here's why they were using it. They believed that if cricoid pressure was applied, which is
usually used when you can't see the epiglottis well. The Sellick's manoeuvre, cricoid pressure was suppose
to help air go into the trachea instead of the esophogus and the stomach.
That was the idea, to help reduce regurgitation and reduce gastric distention.
That's not recommended anymore. So, if you were in the group that was still using that
procedure, it is no longer consistent with the 2010 guidelines. There has been a continued
emphasis placed on the need to reduce the time between the last compression and shock delivery
and the time between shock delivery and resumption of cardiac compressions. That's pretty
consistent in ACLS and for BLS it's being re-emphasized not changed.
The goal is, get the chest compressions going and get the pulse pressures up, get the hemodynamics
stabilized, they're acidic most likely after 6 minutes, so by circulating well, and blowing off
CO2 with a bag valve mask even with room air and delivering chest compressions fast, hard, and deep,
the goal is that we can bring the ph balance back into it's parameters and all the things that go
with that so that when the patient is defibrillated, in V-fib or in V-tack, we can hopefully get them
into an autonomous rythm that is circulating on its own. And really getting those
pulse pressures up and getting really good circulation and getting everything stabilized
hemodynamically again. That's the goal. And the faster we get the chest compressions to defibrillation
and defibrillation to chest compressions the better. And that's where the emphasis is coming back
again. So, what we're really trying to say is let's minimize distractions like, hey, could you print
a strip off for me so I can take a look at that strip, get to the compressions and defibrillation and
back again, you know where your strip is? It's when they're taking better quality breaths on their
own because they are reviving and beginning to move. The best thing that someone could ever do if I
cardioverted them and give me the best success rate, is push my hands off their chest and say
they don't need CPR anymore, that would be awesome. So, let the signs and symptoms be the vote to say
now, we can chill out a bit and see how things are going or keep resuscitating.
There's an increased focus on using the team approach on CPR. This looks similar to the ACLS megacode.
Now, in our training library, we've added this, and I think it's a great idea. In group settings
where you have at least two to four team members, there's a way to choreograph that resuscitation
effort where you have many hands. Now, in my training what I did is I showed that the airway
management person, like in ACLS, has the birds eye view of the code. They make a great team leader,
now your protocols and algorithm may call for something different, follow you local protocols.
But, if you don't have one, I think that's a good default. The person who takes the airway management
and is doing the bag valve mask and is in a really good position to call out and direct and choreograph
who is going to do AED, chest compressions, how's airway management going, we're going to have to
log roll the patient because they vomited, and the team approach really makes for a smooth effective resuscitation.
And we have multiple people to change out for compressions so that fatigue doesn't degrade CPR
and we can continue the quality of compressions.
Last but not least, AED's have come a long ways. Because they are computers, the infant/child pads
send a message to the AED that we've got a different size patient and due to that, the joules dosage is
appropriate for infants one year and less. That's great news. Many of you were still overriding that
with adult pads or manual defibrillation, but AEDs with pediatric pads will reduce the joules
appropriately and attenuate the joule dosages properly for the pediatric patient.
It will show right on the pads where the pads go. We are still using the anterior/posterior method for infants
but that's great news to be able to use the AED. And these are the same AEDs that are coming
off child daycare walls and are located in schools and are becoming more readily available.
But that is something we needed to mention and I think that it is valuable and I hope you keep that in
mind as we move forward into this new five year, this half a decade of new science and new
recommendations. I'm excited to continue training for you and with you. Keep your questions coming
whether it's through RoyOnRescue.com or through the support email address for the customer
solutions department. Let's get going training and let's get you recertified. I hope this
update was helpful for you, dryer than a bone but thank you for hanging in there and staying with me,
and until next time, take care and we'll see you soon.