Changes in Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

Vernie Bacolot, BSN, RN, C

The American Heart Association has made changes to the guidelines for cardiopulmonary resuscitation and emergency cardiovascular care which will take effect in 2006. The major changes include recommendations (a) to improve delivery of effective chest compressions, (b) a single compression-to-ventilation ratio for all single rescuers for all victims (except newborns), (c) that each rescue breath be given over 1 second and should produce visible chest rise, (d) that single shocks, followed by immediate CPR be used to attempt defibrillation for VF cardiac arrest, rhythm checks should be performed every 2 minutes, and (e) endorsement of the 2003 International Liaison Committee on Resuscitation (ILCOR) recommendation for use of AEDs in children 1 to 8 years (and older); use a child dose-reduction system if available.
The summary of major changes to the 2005 AAP/AHA Emergency Cardiovascular Care Guidelines for Neonatal Resuscitation is also included to provide a comprehensive guide to all the changes in life support courses.

Major Changes in ACLS:

• Emphasis on chest compression depth and rate, chest wall recoil, and minimal interruptions
• Increased use of LMA and esophageal-tracheal combitube; endotracheal intubation limited to providers with adequate training
• Endotracheal tube placement confirmation requires both clinical assessment and use of a device (part of primary confirmation).
• Algorithm for treatment of pulseless arrest include VF/pulseless VT, asystole, and PEA.
• Intravenous or intraosseous (IO) drug administration is preferred to endotracheal administration
• Treatment of VF/pulseless VT: defibrillation is 1 shock for monophasic or biphasic followed by CPR, minimize interruptions in chest compressions (interruption only when for ryhthm checks and shock delivery), pulse/rhythm check not needed after shock delivery, may check after 2 minutes of CPR, Drugs should be delivered during CPR as soon as possible after rhythm check, Vasopressors are administered when an IV/IO line is in place if VF or pulseless VT persists after 1st or 2nd shock, Antiarrhythmics may be considered after the first dose of vasopressors, Amiodarone is preferred to lidocaine.
• Treatment of Asystole/PEA: epinephrine q 3 - 5 minutes; 1 dose of vasopressin may replace either first or second dose of epinephrine.
• Treatment of symptomatic bradycardia: atropine 0.5 mg IV, total of 3 mg. Epinephrine or dopamine may be given pending pacemaker placement.
• Treatment of symptomatic tachycardia: a single simplified algorithym includes some but not all drugs that may be administered. Algorithm indicates therapies for in-hospital setting with expert consultation available.
• Consider inducing hypothermia for patient unresponsive but with adequate blood pressure after resuscitation.

Major Changes in PALS:

• Further caution about the use of endotracheal tubes. LMAs are acceptable when used by experienced providers
• Cuffed ETs may be used in infants (except newborns) and children in in-hospital settings provided that cuff inflation is kept >2cm H20
• Confirmation of tube placement requires clincial assessment and assessment of exhaled carbon dioxide; esophageal detector devices may be considered for use in children weighing >20kg who have perfusing rhythm
• During CPR with an advanced airway in place, rescuers will no longer perform "cycles" of CPR, instead rescuers will perform continuous chest compressions at 100/minute without pauses for ventilation.
• Vascular access is preferred to endotracheal drug administration
• Timing 1 shock, CPR, and drug administration during pulseless arrest has changed and is now identical to ACLS
• Routine use of high-dose epinephrine is not recommended
• Lidocaine is deemphasized, but can be used for treatment of VF/pulseless VT if amiodarone is not available
• Induced hypothermia (32°C to 34° C) for 12 to 24 hours may be considered if the child remains comatose after resuscitation

Major Changes in Neonatal Resuscitation:

• Use of oxygen: Research suggests that resuscitation with less than 100% oxygen may just be successful. Recommends use 100% O2 when baby is cyanotic or when PPV is required. Use room air to deliver PPV, if oxygen not available. For premature babies, use oxygen blender and pulse oximeter.
• Meconium: No longer recommend that all meconium stained babies routinely receive intrapartum suctioning. Endotracheal suctioning post delivery is unchanged.
• Devices for assisting ventilation: In assisting ventilation for a newborn, self-inflating bag or flow-inflating bag remains the recommended device; use of a T-piece resuscitator is acceptable.
• Effectiveness of assisted ventilation: Increasing heart rate is the primary sign of effective ventilation. Other signs are improving color, spontaneous breathing, and improving muscle tone.
• Use of CO2 detector: An increasing heart rate and CO2 detection are the primary methods of confirming ET tube placement.
• Laryngeal mask airway: Use of esophageal device in confirming placement is not reliable for patients aged <1 year.
• Epinephrine: Dose of 0.1-0.3 mg/kg by endotracheal route is ineffective; therefore IV administration of 0.01 to 0.03 mg/kg per dose is the preferred route. However, while access is being obtained, administration of a higher dose (up to 0.1 mg/kg) may be considered
• Naloxone: Not recommended during primary steps of resuscitation. Endotracheal administration not recommended (no studies reporting efficacy); IV route preferred, IM acceptable.
• Laryngeal mask airway: Has been shown to be an effective alternative when bag-and-mask ventilation or ET intubation has failed.
• Temperature control: Polyethylene bags may be used to help maintain body temperature during resuscitation of very-low-birth weight babies.
• Withholding or withdrawing resuscitation: Non-initiation and discontinuation of resuscitation of treatment during and after resuscitation are ethically equivalent. Clinicians should not hesitate to withdraw support when functional survival is highly unlikely. When prognosis is uncertain and survival is borderline, parental desires should be supported.
• Discontinuing resuscitation: If there are no signs of life after 10 minutes of continuous active resuscitative efforts, discontinuation may be justified.