New Standards For CPR
Betty J. Romanoff, RN, MN, MA
Masthead Date March 13, 2006
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"One one thousand, two one thousand … Cardiopulmonary resuscitation (CPR) has been practiced in almost the same fashion since its inception in the early 1960s when it was realized that chest compressions combined with mouth-to-mouth breathing could accomplish circulatory and respiratory benefits during cardiac arrest.
Recently, the American Heart Association (AHA) issued new guidelines that will become the standard for CPR. The American Red Cross (ARC) and other CPR-certifying agencies are changing their guidelines as well to incorporate the latest scientific information.
Why and when?
Studies have shown that the old way of doing CPR required learning too many steps and too many details; people were afraid of doing it wrong, so they did nothing at all, much to the detriment of the more than 330,000 individuals who die of cardiac arrest each year. A primary purpose of revising the guidelines for both lay and professional rescuers was “to improve survival from cardiac arrest by increasing the number of victims of cardiac arrest who receive early, high-quality CPR.”1
After July 1, 2006, all AHA courses will be taught using the new guidelines, says Tagni McRae, communications manager, AHA National Center. The AHA will supply “bridge” training materials to give instructors and training centers the information needed to incorporate the new information into the courses.
The Red Cross plans to implement the changes in CPR courses for health care professionals by April 1, 2006, says Pam King, associate in communications and marketing, ARC National Headquarters. For both groups, current CPR cards are considered valid until expiration, after which the new guidelines will be the standard for certification.
How guidelines are decided
The International Liaison Committee on Resuscitation (ILCOR) was formed in 1992 to provide a forum for the coordination of cardiopulmonary and cerebral resuscitation worldwide. This scientific body is currently made up of representatives from the American Heart Association, the European Resuscitation Council, the Heart and Stroke Foundation of Canada, the Australian and New Zealand Committee on Resuscitation, the Resuscitation Councils of Southern Africa, and the Inter-American Heart Foundation.
In 2000, ILCOR, in collaboration with the AHA, produced the first international CPR guidelines. In 2005, ILCOR again convened a group of internationally recognized experts from a variety of countries, cultures, and disciplines to “evaluate and form an expert consensus on all peer-reviewed scientific studies related to CPR and ECC (emergency cardiovascular care).”2 The recommendations that resulted from this group’s work are published in The 2005 International Consensus on Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care
(ECC) Science with Treatment Recommendations (CoSTR).
This document is “the scientific cornerstone of the AHA’s 2005 Guidelines for CPR and
ECC, as well as the basis for treatment guidelines developed for other countries by their resuscitation councils,” says McRae.
The American Red Cross, The American Health Association, and National Safety Council all base their programs on the recommendations from
ILCOR.
Who else certifies?
Certification in CPR is both a necessary skill and a requirement for employment for most health care providers. While the AHA and the ARC are the most well-known certifying agencies, there are other groups that offer nurses basic life support
(BLS), first aid, and bloodborne pathogens certification.
Many public and private companies and organizations offer CPR instruction for health care providers and follow the guidelines set forth by the AHA. These companies may be authorized by the AHA, the ARC, American Health Association, or the American Safety and Health Institute
(ASHI) to issue certification cards. The courses may be taken on-site with an instructor or online.
Online CPR, First Aid, or Bloodborne courses
Among the other groups that offer online training is Professional Training Institute, accredited by the American Health Association, which offers online CPR courses for both lay and professional rescuers, as well as first aid, blood borne pathogen, and automated external defibrillator
(AED) training. These courses meet the guidelines established by the AHA’s Emergency Cardiac Care Committee. The U.S. government’s Federal Occupational Health Agency
(FOH) has adopted these programs to train federal employees nationwide.
“Professional Training Institute has already incorporated the 2005 guideline changes into its web-based courses for CPR,
AED, First Aid, Bloodborne Pathogens. Other online training organizations should be updated sometime this year.
Major Changes in CPR for Health Care Providers
The reason for the changes is to make CPR easier to learn and do, with more chest compressions and fewer interruptions in compressions.
Lone Provider:
- Compression-to-breath rate: 30 compressions to 2 breaths in all victims (excluding newborns) with 100 compressions per minute and each breath lasting 1 second.
Rationale: Less ventilation is needed to provide oxygen during cardiac arrest since pulmonary blood flow is decreased; effective chest compressions optimize blood flow and increase oxygen delivery to heart and brain.
- With sudden collapse, adult and child: call EMS first, get
AED, start CPR, use AED
Rationale: Sudden collapse is likely to be cardiac; early defibrillation is critical.
- With hypoxic arrest (such as drowning, drug overdose, or injury) in all victims, or in case of an unresponsive child/infant, with the exception of a sudden, witnessed collapse: 5 cycles or 2 minutes of CPR first, call EMS, resume
CPR/AED.
Rationale: Hypoxic arrest requires immediate CPR with ventilations and chest compressions before the rescuer leaves to call EMS and get
AED.
- Rescuer must give compressions of sufficient depth and rate and allow chest recoil with minimal interruptions in compressions
Rationale: Chest compressions must be fast and deep enough to provide adequate blood flow to the heart and brain. Chest recoil permits blood to refill heart and allows for sufficient cardiac output with subsequent compressions. Interruption of compressions stops blood flow and decreases coronary artery perfusion.
- Two rescuer CPR for infants and children: compression-to-breath rate of 15 to 2
Rationale: The 15:2 rate allows more ventilations while compressions continue.
- Definition of a child victim is now ages 1 to the onset of puberty
(usually ages 12 to 14, but age may vary). However, for AED, continue to use the definition of a child as ages 1 to 8.
- Two-rescuer infant CPR: 2 thumbs with hands encircling chest method includes thoracic squeeze.
Rationale: This method produces higher coronary artery perfusion pressure and results in more consistent appropriate depth of compression.
- Two rescuer CPR with advanced airway: no pause in compressions for breaths; breaths are given at rate of 8 to 10 per minute.
Rationale: Ventilations can be done during compressions when an airway is in place, allowing for uninterrupted chest compressions. Avoid overventilation because it increases intrathoracic pressure and decreases venous return to heart.
- 2 rescuer CPR: rescuers rotate compressor role every 2 minutes
Rationale: For effective chest compressions, rescuers must avoid fatigue.
- Opening airway in trauma victim: head tilt-chin lift IF jaw thrust ineffective in opening airway
Rationale: Jaw thrust may not open airway, and opening the airway is a priority in an unresponsive victim.
- Check for adequate breathing in adults and presence or absence of breathing in children/infants before giving rescue breaths.
Rationale: Breathing may not be normal but can still be adequate, especially in children.
- Give chest compressions if infant/child heart rate is less than 60/min. With signs of poor perfusion despite adequate oxygenation and ventilation.
Rationale: Bradycardia is common terminal rhythm in infants and children; rescuer should not wait for absence of pulse to begin chest compressions.
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Betty J. Romanoff, RN, MN, MA, is a frequent contributor to Nursing Spectrum.
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References
1. American Heart Association Currents in Emergency Cardiovascular Care. Winter 2005-2006;16(4):2
2. American Heart Association 2005 international consensus on CPR and ECC science with treatment recommendations. Available at
www.c2005.org/presenter.jhtml?identifier=3022512. Accessed January 16, 2006.
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