Why did they change CPR?

-----------2010 CPR / first aid CliffsNotes -------------

Below are some excerpts from the journal Circulation on the 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care with Treatment Recommendations (CoSTR), Guidelines 2010, including CPR/AED and first aid.

see also: Citizen CPR

"There have been several important advances in the science of resuscitation since the 2005 ILCOR review.

The following is a summary of the most important evidence-based recommendations for performance of BLS:

Lay rescuers begin CPR if the adult victim is unresponsive and not breathing normally (ignoring occasional gasps) without assessing the victim's pulse.

Following initial assessment, rescuers begin CPR with chest compressions rather than opening the airway and delivering rescue breathing.

All rescuers, trained or not, should provide chest compressions to victims of cardiac arrest. A strong emphasis on delivering high-quality chest compressions remains essential: push hard to a depth of at least 2 inches (5 cm) at a rate of at least 100 compressions per minute, allow full chest recoil after each compression, and minimize interruptions in chest compressions.

Trained rescuers should also provide ventilations with a compression-ventilation ratio of 30:2.

EMS dispatchers should provide telephone instruction in chest compression-only CPR for untrained rescuers."

"Rescuers begin CPR if the adult victim is unresponsive with absent or abnormal breathing, such as an occasional gasp. A single compression-ventilation ratio of 30:2 is used for the lone lay rescuer of an infant, child, or adult victim (excluding newly borns). This single ratio is designed to simplify teaching, promote skills retention, increase the number of compressions given, and decrease interruptions in compressions. The most significant adult BLS change in this document is a recommendation for a CAB (compressions, airway, breathing) sequence instead of an ABC (airway, breathing, compressions) sequence to minimize delay to initiation of compressions and resuscitation. In other words, rescuers of adult victims should begin resuscitation with compressions rather than opening the airway and delivery of breaths.

Once a defibrillator is attached, if a shockable rhythm is confirmed, a single shock is delivered. Irrespective of the resultant rhythm, CPR starting with chest compressions should resume immediately after each shock to minimize the "no-flow" time (ie, time during which compressions are not delivered, for example, during rhythm analysis)."

"Basic and advanced life support knowledge and skills can deteriorate in as little as 3 to 6 months. Quality of education, frequent assessments and, when needed, refresher training are recommended to maintain resuscitation knowledge and skills. "

"Aspirin In the absence of true allergy, aspirin should be given as soon as possible to patients with suspected ACS. It is reasonable to consider EMS- or dispatcher-guided administration of aspirin by bystanders despite limited direct evidence to support or refute the practice... Administration of aspirin is recommended for chest discomfort if the victim does not have an allergy, a recent episode of bleeding, or other contraindications to aspirin, but administration of aspirin should never delay activation of EMS. "

Pediatric: "Family presence during resuscitations has been shown to be beneficial for the grieving process and in general was not found to be disruptive. Thus, family presence is supported if it does not interfere with the resuscitative effort."

"It is reasonable to wear personal protective equipment (eg, gloves) when performing CPR. CPR should not be delayed or withheld if personal protective equipment is not available unless there is a clear risk to the rescuer."

"AED use should not be restricted to trained personnel. Allowing the use of AEDs by persons without prior formal training can be beneficial and may be lifesaving. Because even brief training improves performance (eg, speed of use, correct pad placement), it is recommended that training in the use of AEDs be provided."

"Rescuer Fatigue

When performing chest compressions, if feasible, it is reasonable to consider changing rescuers after about 2 minutes to prevent rescuer fatigue (demonstrated by deterioration in chest compression quality, in particular, depth of compressions). The change of rescuers performing chest compressions should be done with minimal interruption in compressions."

"Psychological Effects

There are few reports of psychological harm to rescuers after they are involved in a resuscitation attempt. There is insufficient evidence to support or refute any recommendation on minimizing the incidence of psychological harm to rescuers.

Disease Transmission

The risk of disease transmission during training and actual CPR performance is very low. Rescuers should take appropriate safety precautions, especially if a victim is known to have a serious infection (eg, human immunodeficiency virus [HIV], tuberculosis, hepatitis B virus, or severe acute respiratory syndrome [SARS]).

Rescuer Willingness to Respond

Increasing the willingness of individuals to respond to a cardiac arrest with early recognition, calling for help, and starting CPR is essential to improve survival rates.

To increase willingness to perform CPR, laypersons should receive training in CPR that includes recognition of gasping or abnormal breathing as a sign of adult cardiac arrest when other signs of life are absent. Laypersons should be trained to start resuscitation with chest compressions in adult and pediatric victims. If unwilling or unable to perform ventilations, rescuers should be instructed to continue compression-only CPR. EMS dispatchers should provide chest compression-only CPR instructions to callers who report adult cardiac arrest and these instructions should include recognition of gasping and abnormal breathing."

"There is no evidence that turning an unresponsive, spontaneously breathing victim into any side-lying versus a supine position is beneficial. If a person with a suspected cervical spine injury is turned to the side, the HAINES position appears to be safer than the lateral recumbent position."

tourniquets

"Since the 2005 scientific review, new data have become available about the effect of tourniquets to control bleeding. This experience comes primarily from the battlefields of Iraq and Afghanistan. There is no question that tourniquets do control bleeding, but when tourniquets remain in place too long, reported complications include gangrene distal to the application, shock, and death. Protocols for the proper use of tourniquets to control bleeding exist, but there is no experience with civilian use or how to teach the proper application of tourniquets to first aid providers. Studies have shown that not all tourniquets are the same, and some manufactured tourniquets perform better than others and better than improvised ones. This issue will take on increasing importance in this age of terrorism and the possibility of mass casualties during disasters. "

"Properly applied tourniquets do control hemorrhage under surgical and battlefield conditions, but because of potential complications, there are insufficient data for or against recommending their routine use in civilian first aid ... In civilian settings, tourniquets should only be used for control of extremity hemorrhage if direct pressure is not adequate or possible (eg, multiple injuries, inaccessible wounds, multiple victims). Specifically designed tourniquets are superior to improvised ones but should only be used with proper training. There is insufficient evidence to determine how long a tourniquet can remain in place safely. Cooling of the distal limb should be considered if a tourniquet needs to remain in place for a prolonged period of time. "

"Cooling of thermal burns with tap water is recommended as soon as possible but no later than 30 minutes after the injury. Large burns should not be cooled without the ability to monitor the victim's core temperature because that may cause hypothermia, especially in children. Cooling with ice or ice water is not recommended. "

"Burn blisters should be left intact. "

"Control of bleeding is best achieved with direct manual pressure over the bleeding area. Pressure can be maintained by applying an elastic adhesive bandage over gauze pads. There is evidence against using pressure points (indirect pressure) but no evidence for or against elevation of the bleeding part as a method of hemorrhage control. "

"In general, there should be no attempt to manipulate a suspected extremity fracture."

"There is insufficient evidence for or against the application of heat to an acute musculoskeletal injury. Cold application appears to be superior in the early reduction of edema...Musculoskeletal, including joint, injuries should be treated with the application of ice (crushed or cubed) with water. Cooling time should be interrupted every 20 minutes. Intermittent 10-minute cooling is also acceptable if 20 minutes of cooling causes discomfort. "

"Irrigation of acute superficial wounds with a large volume of warm or room temperature tap water from a reliable source (with or without soap) is recommended. ...After cleaning, superficial traumatic abrasions should be covered with a clean occlusive dressing and/or a topical antibiotic that keeps the wound moist and prevents drying. There are insufficient data to recommend any particular dressing or topical antibiotic. "

"Immediate irrigation of eyes exposed to a toxin with large amounts of tap water is beneficial."

"Irrigation of human and animal bite wounds with a copious amount of fluid (water or saline) is recommended to minimize the risks of bacterial and rabies infections. There is no evidence for or against any specific irrigation fluid. "

"Suction should not be applied to treat snake envenomation; it is ineffective and may be harmful. "

"Pressure immobilization bandages are not recommended for the treatment of jellyfish stings. ...Jellyfish stings should be liberally washed with vinegar (4% to 6% acetic acid solution) as soon as possible for at least 30 seconds to prevent further envenomation and/or to inactivate nematocysts. If vinegar is not available, baking soda slurry may be used instead. Topical application of aluminum sulfate or meat tenderizer is not recommended for the relief of pain. ..After the nematocysts are removed or deactivated, the pain caused by jellyfish stings should be treated with hot-water immersion when possible. The victim should be instructed to take a hot shower or immerse the affected part in hot water (temperature as hot as tolerated, or at 45°C if there is the capability to regulate temperature) as soon as possible. The immersion should continue for at least 20 minutes, or for as long as pain persists. If hot water is not available, dry hot packs or, as a second choice, dry cold packs may also be helpful in decreasing pain. "

"When providing first aid to a victim of frostbite, rewarming of frozen body parts is only beneficial if there is no risk of refreezing. For severe frostbite, rewarming should be accomplished within 24 hours.

Rewarming is best achieved by immersing the affected part in water between 37°C and 40°C (ie, body temperature) for 20 to 30 minutes. Chemical warmers should not be placed directly on frostbitten tissue because they can reach temperatures that can cause burns. Following rewarming, efforts should be made to protect frostbitten parts from refreezing and to quickly evacuate the victim for further care... There is insufficient evidence for or against the use of ibuprofen or other NSAIDs as a first aid measure for victims of frostbite. "

"Exercise-related hypohydration should be treated with an oral carbohydrate/electrolyte solution. Milk is an acceptable alternative. The volume consumed should exceed the volume lost in sweat. "

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-----------2005-------------

I am leaving a few quotes of interest from 2005:

For the single rescuer of an infant (except newborns), child, or adult victim, use a single compression-ventilation ratio of 30:2 to simplify teaching, promote skills retention, increase the number of compressions given, and decrease interruptions in compressions.

Checking the carotid pulse is an inaccurate method of confirming the presence or absence of circulation; however, there is no evidence that checking for movement, breathing, or coughing (ie, "signs of circulation") is diagnostically superior. Agonal gasps are common in the early stages of cardiac arrest. Bystanders often report to dispatchers that victims of cardiac arrest are "breathing" when they demonstrate agonal gasps; this can result in the withholding of CPR from victims who might benefit from it.

Treatment Recommendation: Rescuers should start CPR if the victim is unconscious (unresponsive), not moving, and not breathing. Even if the victim takes occasional gasps, rescuers should suspect that cardiac arrest has occurred and should start CPR.

There is insufficient evidence that any specific compression-ventilation ratio is associated with improved outcome in patients with cardiac arrest. To increase the number of compressions given, minimize interruptions of chest compressions, and simplify instruction for teaching and skills retention, a single compression-ventilation ratio of 30:2 for the lone rescuer of an infant, child, or adult victim is recommended.

Rib fractures and other injuries are common but acceptable consequences of CPR given the alternative of death from cardiac arrest. After resuscitation all patients should be reassessed and reevaluated for resuscitation-related injuries.

Emphasis on the quality of pediatric CPR is increased: "Push hard, push fast, minimize interruptions; allow full chest recoil, and don’t hyperventilate"

The pulse check was previously eliminated as an assessment for the lay rescuer. There is now evidence that healthcare professionals may take too long to check for a pulse and may not accurately determine the presence or absence of the pulse. This may lead to interruptions in chest compressions and affect the quality of CPR.

Foreign-Body Airway Obstruction

Four case reports documented harm to the victim’s mouth or biting of the rescuer’s finger (while using a finger sweep).

Chest thrusts, back blows/slaps, or abdominal thrusts are effective for relieving FBAO in conscious adults and children >1 year of age, although injuries have been reported with the abdominal thrust. There is insufficient evidence to determine which should be used first. These techniques should be applied in rapid sequence until the obstruction is relieved; more than one technique may be needed. Unconscious victims should receive CPR. The finger sweep should be used in the unconscious patient with an obstructed airway only if solid material is visible in the airway.

Higher airway pressures can be generated by using the chest thrust rather than the abdominal thrust.

Chest Compression–Only CPR

Consensus on Science

No prospective studies have assessed the strategy of implementing chest compression–only CPR. A randomized trial of telephone instruction in CPR given to untrained lay responders in an EMS system with a short (mean: 4 minutes) response interval suggests that a strategy of teaching chest compressions alone is associated with similar survival rates when compared with a strategy of teaching chest compressions and ventilations.

Treatment Recommendation

Rescuers should be encouraged to do compression-only CPR if they are unwilling to do airway and breathing maneuvers or if they are not trained in CPR or are uncertain how to do CPR.