Highlights of the 2010 Guidelines for CPR and ECC - ECC Guidelines

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lp ae y d ira et sr i c u eA r L Sa d u lt c p r Why: Newer case reports suggest that an AED may be safe and effective in infants. Because survival requires defibrillation when a shockable rhythm is present during cardiac arrest, delivery of a high-dose shock is preferable to no shock. Limited evidence supports the safety of AED use in infants. • Providers are advised to seek expert consultation, if possible, when administering amiodarone or procainamide to hemodynamically stable patients with arrhythmias. • The definition of wide-complex tachycardia has been changed from >0.08 second to >0.09 second. PEDIATRIC ADVANCED LIFE SUPPORT Summary of Key Issues and Major Changes • Many key issues in the review of the PALS literature resulted in refinement of existing recommendations rather than new recommendations; new information is provided for resuscitation of infants and children with selected congenital heart defects and pulmonary hypertension. • Monitoring capnography/capnometry is again recommended to confirm proper endotracheal tube position and may be useful during CPR to assess and optimize the quality of chest compressions. • The PALS cardiac arrest algorithm was simplified to emphasize organization of care around 2-minute periods of uninterrupted CPR. • The initial defibrillation energy dose of 2 to 4 J/kg of either monophasic or biphasic waveform is reasonable; for ease of teaching, a dose of 2 J/kg may be used (this dose is the same as in the 2005 recommendation). For second and subsequent doses, give at least 4 J/kg. Doses higher than 4 J/kg (not to exceed 10 J/kg or the adult dose) may also be safe and effective, especially if delivered with a biphasic defibrillator. • On the basis of increasing evidence of potential harm from high oxygen exposure, a new recommendation has been added to titrate inspired oxygen (when appropriate equipment is available), once spontaneous circulation has been restored, to maintain an arterial oxyhemoglobin saturation ≥94% but
p e d i a t r i c A L S Why: More data are needed to identify the optimal energy dose for pediatric defibrillation. Limited evidence is available about effective or maximum energy doses for pediatric defibrillation, but some data suggest that higher doses may be safe and potentially more effective. Given the limited evidence to support a change, the new recommendation is a minor modification that allows higher doses up to the maximum dose most experts believe is safe. Limiting Oxygen to Normal Levels After Resuscitation 2010 (New): Once the circulation is restored, monitor arterial oxyhemoglobin saturation. It may be reasonable, when the appropriate equipment is available, to titrate oxygen administration to maintain the arterial oxyhemoglobin saturation ≥94%. Provided appropriate equipment is available, once ROSC is achieved, adjust the Fio 2 to the minimum concentration needed to achieve arterial oxyhemoglobin saturation ≥94%, with the goal of avoiding hyperoxia while ensuring adequate oxygen delivery. Because an arterial oxyhemoglobin saturation of 100% may correspond to a Pao 2 anywhere between approximately 80 and 500 mm Hg, in general it is appropriate to wean the Fio 2 when the saturation is 100%, provided the saturation can be maintained ≥94%. 2005 (Old): Hyperoxia and the risk for reperfusion injury were addressed in the 2005 AHA Guidelines for CPR and ECC in general, but recommendations for titration of inspired oxygen were not as specific. Why: In effect, if equipment to titrate oxygen is available, titrate oxygen to keep the oxyhemoglobin saturation 94% to 99%. Data suggest that hyperoxemia (ie, a high Pao 2 ) enhances the oxidative injury observed after ischemiareperfusion such as occurs after resuscitation from cardiac arrest. The risk of oxidative injury may be reduced by titrating the Fio 2 to reduce the Pao 2 (this is accomplished by monitoring arterial oxyhemoglobin saturation) while ensuring adequate arterial oxygen content. Recent data from an adult study 5 demonstrated worse outcomes with hyperoxia after resuscitation from cardiac arrest. Resuscitation of Infants and Children With Congenital Heart Disease 2010 (New): Specific resuscitation guidance has been added for management of cardiac arrest in infants and children with single-ventricle anatomy, Fontan or hemi-Fontan/ bidirectional Glenn physiology, and pulmonary hypertension. 2005 (Old): These topics were not addressed in the 2005 AHA Guidelines for CPR and ECC. Why: Specific anatomical variants with congenital heart disease present unique challenges for resuscitation. The 2010 AHA Guidelines for CPR and ECC outline recommendations in each of these clinical scenarios. Common to all scenarios is the potential early use of extracorporeal membrane oxygenation as rescue therapy in centers with this advanced capability. Management of Tachycardia 2010 (New): Wide-complex tachycardia is present if the QRS width is >0.09 second. 2005 (Old): Wide-complex tachycardia is present if the QRS width is >0.08 second. Why: In a recent scientific statement, 6 QRS duration was considered prolonged if it was >0.09 second for a child under the age of 4 years, and ≥0.1 second was considered prolonged for a child between the ages of 4 and 16 years. For this reason, the PALS guidelines writing group concluded that it would be most appropriate to consider a QRS width >0.09 second as prolonged for the pediatric patient. Although the human eye is not likely to appreciate a difference of 0.01 second, a computer interpretation of the ECG can document the QRS width in milliseconds. Medications During Cardiac Arrest and Shock 2010 (New): The recommendation regarding calcium administration is stronger than in past AHA Guidelines: routine calcium administration is not recommended for pediatric cardiopulmonary arrest in the absence of documented hypocalcemia, calcium channel blocker overdose, hypermagnesemia, or hyperkalemia. Routine calcium administration in cardiac arrest provides no benefit and may be harmful. Etomidate has been shown to facilitate endotracheal intubation in infants and children with minimal hemodynamic effect but is not recommended for routine use in pediatric patients with evidence of septic shock. 2005 (Old): Although the 2005 AHA Guidelines for CPR and ECC noted that routine administration of calcium does not improve the outcome of cardiac arrest, the words “is not recommended” in the 2010 AHA Guidelines for CPR and ECC provide a stronger statement and indicate potential harm. Etomidate was not addressed in the 2005 AHA Guidelines for CPR and ECC. Why: Stronger evidence against the use of calcium during cardiopulmonary arrest resulted in increased emphasis on avoiding the routine use of this drug except for patients with documented hypocalcemia, calcium channel blocker overdose, hypermagnesemia, or hyperkalemia. Evidence of potential harm from the use of etomidate in both adults and children with septic shock led to the recommendation to avoid its routine use in this setting. Etomidate causes adrenal suppression, and the endogenous steroid response may be critically important in patients with septic shock. Highlights of the 2010 AHA Guidelines for CPR and ECC 21
Page 1 and 2: Highlights of the 2010 A m e r i c
Page 3 and 4: This “Guidelines Highlights” pu
Page 5 and 6: LAY RESCUER ADULT CPR H e allt a y
Page 7 and 8: H e a lt h C a r e P r o v i d e r
Page 11 and 12: e l e c t r i c a l t h e r a p i e
Page 13 and 14: e l e c t r i c a l t h e r a p i e
Page 15 and 16: ADVANCED CARDIOVASCULAR LIFE SUPPOR
Page 17 and 18: A C L S the likelihood of ROSC. Bef
Page 19 and 20: a c u t e c o r o n a r y s y n d r
Page 21: p e d i a t r i c B L S • De-emph
Page 25 and 26: n e o n a t a l r e s u s c i t a t
Page 27 and 28: e d u c a t i o n , i m p l e m e n
Page 29 and 30: H e a lt h C a r e P r o vf i id re

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