Latest and Greatest: Overview 2015 American Heart Association Emergency Cardiovascular Care Updates
New basic Life Support Algorithms for Pediatric Cardiac Arrest
Pediatric cardiac arrest often occurs as a result of shock or prolonged respiratory failure rather than cardiac causes. In 0.7% to 3% of hospital admissions and 1.8% to 5.5% of intensive care unit admissions, cardiac arrest develop, bringing about significant economic losses to the society, the patients, and their families.
The American Heart Association Emergency Cardiovascular Updates has recently released new algorithms for the management of cardiac arrest in the pediatrics group. Two algorithms were released- one for the single rescuer and another for two or more rescuers. The modifications were made in order to adapt with the current generation where mobile phones and other communications devices are widely available and avidly used. Despite the major change, the algorithms remain focused on ensuring that correct cardiopulmonary resuscitation (CPR) is delivered to the patient.
The 2015 algorithm requires verification of the scene safety prior to assessment of the victim. Upon seeing an unresponsive patient, the rescuer should immediately shout for help. If there is a single rescuer, the emergency response system should be activated via mobile device. However, if there are multiple rescuers, one rescuer remains with the patient and another activates the emergency response system and retrieves the AED as well as the emergency equipment. In the 2010 algorithm, if the rescuer is alone, he should send someone to activate the emergency response system and get the AED or defibrillator. For sudden collapse, the lone rescuer himself should carry out the activation of the system and get the equipment as well.
In the 2010 algorithm, the next step would be to check for the patient’s pulse. If the patient has definite pulse, one breath every 3 seconds should be given. Compressions should be added in cases where the pulse remains below 60 per minute and the perfusion is deprived despite enough oxygenation and ventilation. If the victim is pulseless and only one rescuer is present, cycles of 30 compressions and 2 breaths should be started. Should there be two rescuers, cycles of 15 compressions and 2 breaths should be given. After about 2 minutes, an automated external defibrillator (AED) should be used immediately. The rhythm is then checked and if shockable, 1 shock is given and CPR is started for another two minutes. If not shockable, CPR is continued and rhythm is checked every 2 minutes until advanced life support (ALS) providers take over or the victim moves.
In the 2015 algorithm on the other hand, both breathing and pulse are assessed. If the patient has normal breathing and pulse and only one rescuer is present, the rescuer must activate the emergency response system and watch over the victim until help arrives. Should there be multiple rescuers, the rescuer monitors the patient until his companions arrive. If the patient has pulse but breathing remains abnormal, rescue breathing of 1 breath every 3-5 seconds (or 12-20 breaths per minute) should be started. If the patient is bradycardic, compressions should be initiated and emergency response should be activated within 2 minutes (if not done yet). The pulse is then monitored every 2 minutes and if absent, cardiopulmonary resuscitation is started. These 2015 updates are applied in both single and multiple rescuers.
Moreover, the 2015 algorithm instructs that if both breathing and pulse are absent, or only gasping is present, CPR should be done immediately. Fur multiple rescuers, a cardiopulmonary resuscitation with 30:2 compressions to breath rescue is done and AED is used immediately once available. Upon the arrival of a second rescuer, 15:2 ratio is used. If only one rescuer is present, the same sequence is followed, however after two minutes without help, the rescuer should activate the emergency response system and obtain the AED.
If the lone rescuer saw that the patient collapsed, 2015 algorithm recommends that he activate emergency response system, obtain the AED, and proceed with CPR.
As with the 2010 recommendations, rhythm is then checked and if shockable, 1 shock is given and CPR is started for another two minutes. If not shockable, CPR is continued and rhythm is checked every 2 minutes until advanced life support (ALS) providers take over or the victim moves.
Furthermore, the 2015 guidelines reiterated the preference of using the C-A-B (Compression-Airway-Breathing) order for pediatric cardiopulmonary resuscitation suggested back in 2010 as there has been no new published data that refutes the sequence. In 2010, the recommendation was that at least one third of the AP diameter of the chest must be compressed- equivalent to 1.5 inches in infants and 2 inches in children.
Kleinman ME, Chameides L, Schexnayder SM, et al. Part 14: pediatric advanced life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122(18 suppl 3):S876–S908pmid:20956230
Matos RI, Watson RS, Nadkarni VM, Huang HH, Berg RA, Meaney PA, Carroll CL, Berens RJ, Praestgaard A, Weissfeld L, Spinella PC; American Heart Association’s Get With The Guidelines–Resuscitation (Formerly the National Registry of Cardiopulmonary Resuscitation) Investigators. Duration of cardiopulmonary resuscitation and illness category impact survival and neurologic outcomes for in-hospital pediatric cardiac arrests. Circulation. 2013;127:442–451. doi: 10.1161/CIRCULATIONAHA.112.125625.