New ACLS Guidelines
FROM: http://www2.nurseweek.com/Articles/article.cfm?AID=22842
After years of ABC (airway, breathing, and circulation), early defibrillation, and drug therapy, the American Heart Association (AHA) has returned the focus to the basics of cardiopulmonary resuscitation (CPR) — effective chest compressions. High-quality CPR and early defibrillation are now recognized as the best hope for successful resuscitation and survival to hospital discharge. These interventions are significantly more important than placement of an advanced airway or administration of drugs.
In November 2005, the AHA released a major revision of its CPR and emergency cardiovascular care (ECC) guidelines, the gold standard for resuscitation efforts. This article summarizes some of the key changes in adult Advanced Cardiac Life Support (ACLS) from the 2005 AHA Guidelines for CPR and ECC.
Streamlined approach
The guidelines incorporate several algorithms into one called Pulseless Arrest (see Figure 1), making it easier to use in clinical practice. Although other algorithms such as symptomatic tachycardia have also been revised, this article is limited to pulseless arrest in adults. It highlights changes — and the rationale behind them — in three areas: CPR, defibrillation, and drugs. Implications for nurses are included.
Cardiopulmonary resuscitation
“The most significant change [in the guidelines] is the increased emphasis on high-quality CPR,” says Mary Fran Hazinski, RN, MSN, senior science editor, ECC Programs, American Heart Association.
Rather than advanced airway placement and drugs, the emphasis is on uninterrupted CPR and early defibrillation for patients in ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT). The new rate of CPR chest compressions to ventilations is 30:2 for one-rescuer and two-rescuer CPR in adults. Pay special attention to chest compressions. Rescuers should “push hard, push fast” and only interrupt chest compressions when absolutely necessary.
That’s not to say adequate ventilation is unimportant; it contributes to survival from prolonged arrest. However, the new guidelines remind us that patients need lower ventilation rates because of low pulmonary blood flow.
Ventilations do not need to be sequenced with compressions once an advanced airway (i.e., endotracheal or ET tube, combitube, or laryngeal face mask) is in place: Compressions should be delivered at 100 per minute and breaths at 8 to 10 per minute (1 breath, lasting 1 second, every 6 to 8 seconds).
Nursing Points: Too often clinicians, including nurses, don’t give CPR the attention it deserves. They may feel overconfident because they have been doing CPR for many years. But research doesn’t back up this perceived expertise. “High-quality CPR with minimal interruption gives the victim the best opportunity for survival, “ says Hazinski, “yet we have more and more evidence that chest compressions performed are often too shallow and too slow and are interrupted too frequently during resuscitative efforts.”
In addition, studies show that chest compressions are not performed during 24% to 49% of CPR time. With the increased emphasis on chest compressions, it’s important to check your technique, including allowing the chest to recoil completely after each compression.
The new guidelines note that insertion of an advanced airway may not be a high priority. However, in the hospital setting, ET insertion is likely to be done fairly soon in an arrest, so you should know about a new recommendation: Use two (not one) methods to confirm placement of an ET tube. These methods are clinical assessment (e.g., auscultation for bilateral breath sounds) and a device such as an exhaled CO2 detector or an esophageal detector device. Many hospitals already use these devices, but if yours does not, you might want to suggest adding one of them to your protocol.
Defibrillation
Health care providers still need to provide immediate CPR until a defibrillator is available. However, the stacked shocks of defibrillation are gone, replaced by a single shock. You can attribute the change to the availability of biphasic defibrillators, which have a higher first shock efficacy, typically more than 90%. In addition, taking time to deliver multiple shocks interrupts chest compressions.
Another big difference: CPR should resume immediately after defibrillation and continue for five cycles, or about two minutes. Only then should CPR be stopped for a rhythm check (although the guidelines acknowledge that the sequence may be modified in a monitored setting). Take time to do a pulse check only if the rhythm is likely to be associated with a pulse.
Nurses can play a leadership role in this area. Hazinski says, “Nurses provide the structure and time keeping during resuscitation attempts. They are in the best position to ensure that CPR is being performed with minimal interruption.”
Nursing Points: Each biphasic defibrillator should have a sticker with the recommended level for a shock based on types of waveforms. For a biphasic defibrillator, you’ll typically use 120 to 200 J (joules) for the first shock and the same or higher level for subsequent defibrillations. If you don’t know the recommended level, use 200 J, and if you have a monophasic defibrillator, use 360 J. Continue CPR while the defibrillator is being charged, only stopping when it is time to clear the area so a shock can be delivered. Researchers report that reducing the time between stopping compressions and defibrillation by as little as 15 seconds can increase the success rate of the shock.
Drugs
“No placebo-controlled study has shown that any medication or vasopressor given routinely at any stage during human cardiac arrest increases the rate of neurologically-intact survival to hospital discharge,” says Hazinski. This statement backs up the decreased emphasis on drug administration during sudden cardiac arrest (SCA).
Nursing Points: When drugs are used, they should be administered as soon as possible after the rhythm check and during CPR. Therefore, be sure to have drugs ready to give before the rhythm check is done.
Medication use is summarized in Table 1. In all cases, IV or intraosseous (IO) drug administration is preferred over ET administration, which is associated with lower blood concentration of drugs. In addition, animal studies suggest that ET administration of epinephrine can lead to lower coronary artery perfusion and decrease the likelihood for return of spontaneous circulation. IO has usually been considered more as an option for pediatric patients, but new kits are making this a viable choice for adults too.
Nursing Points: To correctly administer a drug through a peripheral IV line: Inject the drug, follow it with a 20-mL bolus of IV fluid, and then elevate the extremity for 10 to 20 seconds to facilitate drug delivery.
Sequencing of drug administration is less important than not interrupting chest compressions.
Vasopressors are usually given if the VF or pulseless VT persists after the second shock.
Epinephrine may be given every 3 to 5 minutes, and a single dose of vasopressin may substitute for the first or second dose of epinephrine.
Antiarhthymics are considered after the first dose of vasopressors.
Magnesium should be considered if the cardiac rhythm is torsade de pointes.
Of course, from the beginning of the resuscitation effort, clinicians should consider possible causes. This is particularly important for PEA (pulseless electrical activity), which is often reversible if the cause is found and treated.
Nurses’ responsibilities
“The total approach to resuscitation takes a team effort,” says Hazinski. “Nurses are usually the ones charging the defibrillator and administering drugs, so they will be critical in ensuring that the team interrupts compressions as little as possible.”
All nurses should understand the changes in ACLS so they can incorporate them into their practice as they are rolled out by their facilities. None of the changes requires an immediate revision in policy. The teaching materials for ACLS will not be available until summer or fall 2006, so hospitals may choose to wait until then to make policy changes. When it’s time, know that implementing these changes may help you improve your patient’s opportunity for surviving sudden cardiac arrest.
After years of ABC (airway, breathing, and circulation), early defibrillation, and drug therapy, the American Heart Association (AHA) has returned the focus to the basics of cardiopulmonary resuscitation (CPR) — effective chest compressions. High-quality CPR and early defibrillation are now recognized as the best hope for successful resuscitation and survival to hospital discharge. These interventions are significantly more important than placement of an advanced airway or administration of drugs.
In November 2005, the AHA released a major revision of its CPR and emergency cardiovascular care (ECC) guidelines, the gold standard for resuscitation efforts. This article summarizes some of the key changes in adult Advanced Cardiac Life Support (ACLS) from the 2005 AHA Guidelines for CPR and ECC.
Streamlined approach
The guidelines incorporate several algorithms into one called Pulseless Arrest (see Figure 1), making it easier to use in clinical practice. Although other algorithms such as symptomatic tachycardia have also been revised, this article is limited to pulseless arrest in adults. It highlights changes — and the rationale behind them — in three areas: CPR, defibrillation, and drugs. Implications for nurses are included.
Cardiopulmonary resuscitation
“The most significant change [in the guidelines] is the increased emphasis on high-quality CPR,” says Mary Fran Hazinski, RN, MSN, senior science editor, ECC Programs, American Heart Association.
Rather than advanced airway placement and drugs, the emphasis is on uninterrupted CPR and early defibrillation for patients in ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT). The new rate of CPR chest compressions to ventilations is 30:2 for one-rescuer and two-rescuer CPR in adults. Pay special attention to chest compressions. Rescuers should “push hard, push fast” and only interrupt chest compressions when absolutely necessary.
That’s not to say adequate ventilation is unimportant; it contributes to survival from prolonged arrest. However, the new guidelines remind us that patients need lower ventilation rates because of low pulmonary blood flow.
Ventilations do not need to be sequenced with compressions once an advanced airway (i.e., endotracheal or ET tube, combitube, or laryngeal face mask) is in place: Compressions should be delivered at 100 per minute and breaths at 8 to 10 per minute (1 breath, lasting 1 second, every 6 to 8 seconds).
Nursing Points: Too often clinicians, including nurses, don’t give CPR the attention it deserves. They may feel overconfident because they have been doing CPR for many years. But research doesn’t back up this perceived expertise. “High-quality CPR with minimal interruption gives the victim the best opportunity for survival, “ says Hazinski, “yet we have more and more evidence that chest compressions performed are often too shallow and too slow and are interrupted too frequently during resuscitative efforts.”
In addition, studies show that chest compressions are not performed during 24% to 49% of CPR time. With the increased emphasis on chest compressions, it’s important to check your technique, including allowing the chest to recoil completely after each compression.
The new guidelines note that insertion of an advanced airway may not be a high priority. However, in the hospital setting, ET insertion is likely to be done fairly soon in an arrest, so you should know about a new recommendation: Use two (not one) methods to confirm placement of an ET tube. These methods are clinical assessment (e.g., auscultation for bilateral breath sounds) and a device such as an exhaled CO2 detector or an esophageal detector device. Many hospitals already use these devices, but if yours does not, you might want to suggest adding one of them to your protocol.
Defibrillation
Health care providers still need to provide immediate CPR until a defibrillator is available. However, the stacked shocks of defibrillation are gone, replaced by a single shock. You can attribute the change to the availability of biphasic defibrillators, which have a higher first shock efficacy, typically more than 90%. In addition, taking time to deliver multiple shocks interrupts chest compressions.
Another big difference: CPR should resume immediately after defibrillation and continue for five cycles, or about two minutes. Only then should CPR be stopped for a rhythm check (although the guidelines acknowledge that the sequence may be modified in a monitored setting). Take time to do a pulse check only if the rhythm is likely to be associated with a pulse.
Nurses can play a leadership role in this area. Hazinski says, “Nurses provide the structure and time keeping during resuscitation attempts. They are in the best position to ensure that CPR is being performed with minimal interruption.”
Nursing Points: Each biphasic defibrillator should have a sticker with the recommended level for a shock based on types of waveforms. For a biphasic defibrillator, you’ll typically use 120 to 200 J (joules) for the first shock and the same or higher level for subsequent defibrillations. If you don’t know the recommended level, use 200 J, and if you have a monophasic defibrillator, use 360 J. Continue CPR while the defibrillator is being charged, only stopping when it is time to clear the area so a shock can be delivered. Researchers report that reducing the time between stopping compressions and defibrillation by as little as 15 seconds can increase the success rate of the shock.
Drugs
“No placebo-controlled study has shown that any medication or vasopressor given routinely at any stage during human cardiac arrest increases the rate of neurologically-intact survival to hospital discharge,” says Hazinski. This statement backs up the decreased emphasis on drug administration during sudden cardiac arrest (SCA).
Nursing Points: When drugs are used, they should be administered as soon as possible after the rhythm check and during CPR. Therefore, be sure to have drugs ready to give before the rhythm check is done.
Medication use is summarized in Table 1. In all cases, IV or intraosseous (IO) drug administration is preferred over ET administration, which is associated with lower blood concentration of drugs. In addition, animal studies suggest that ET administration of epinephrine can lead to lower coronary artery perfusion and decrease the likelihood for return of spontaneous circulation. IO has usually been considered more as an option for pediatric patients, but new kits are making this a viable choice for adults too.
Nursing Points: To correctly administer a drug through a peripheral IV line: Inject the drug, follow it with a 20-mL bolus of IV fluid, and then elevate the extremity for 10 to 20 seconds to facilitate drug delivery.
Sequencing of drug administration is less important than not interrupting chest compressions.
Vasopressors are usually given if the VF or pulseless VT persists after the second shock.
Epinephrine may be given every 3 to 5 minutes, and a single dose of vasopressin may substitute for the first or second dose of epinephrine.
Antiarhthymics are considered after the first dose of vasopressors.
Magnesium should be considered if the cardiac rhythm is torsade de pointes.
Of course, from the beginning of the resuscitation effort, clinicians should consider possible causes. This is particularly important for PEA (pulseless electrical activity), which is often reversible if the cause is found and treated.
Nurses’ responsibilities
“The total approach to resuscitation takes a team effort,” says Hazinski. “Nurses are usually the ones charging the defibrillator and administering drugs, so they will be critical in ensuring that the team interrupts compressions as little as possible.”
All nurses should understand the changes in ACLS so they can incorporate them into their practice as they are rolled out by their facilities. None of the changes requires an immediate revision in policy. The teaching materials for ACLS will not be available until summer or fall 2006, so hospitals may choose to wait until then to make policy changes. When it’s time, know that implementing these changes may help you improve your patient’s opportunity for surviving sudden cardiac arrest.
Click here to view ACLS chart. (129K, requires Adobe Acrobat).
Cynthia Saver, RN, MS, is president of CLS Development, Inc., Columbia, Md., which provides knowledge-based services for nurses.
References
1. American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care (multiple parts). Circulation. 2005;112(suppl IV).
2. Hazinski MF, Nadkarni VM, Hickey RW, et al. Major changes in the 2005 AHA guidelines for CPR and ECC: Reaching the tipping point for change. Circulation. 1005;112(suppl IV):IV-206-IV-211. Editorial.
3. Highlights of the 2005 American Heart Association guidelines for cardiopulmonary and emergency cardiovascular care. Currents in Emergency
