New York State Protocols

1
New York State Protocols

• Update 2006
• Including AHA changes

2
American Heart Association

• Approximately 330,000 prehospital and Emergency
  Department deaths/year in US are from cardiac
  arrest
• Survival is 6.4 or less
• Changes in AHA guidelines are based on research

3
Major Changes for Everyone

• Emphasis on effective chest compressions
• Universal compressionventilation ratio for lone
  rescuer
• 1 Second breaths during CPR
• 1 Shock, then immediate CPR

4
Effective Chest Compressions

• Change
• Push hard and push fast
• Why
• Need adequate rate and depth in order to produce
  blood flow and perfuse vital organs
• Change
• Equal compression/relaxation times
• Why
• Need full recoil of chest in order to have
  better blood flow
• Change - not emphasized

5
Effective Chest Compressions, continued

• Change
• Limit Interruptions to chest compressions
• Why
• Blood flow stops when CPR is interrupted, more
  compressions in a row provides better blood flow
• Change never limited

6
Universal CompressionVentilation Ratio

• Change
• 302 for lone rescuer, infants through adults
  (not newborns)
• Why
• Simplify information, longer series of
  uninterrupted compressions
• Changed from - 152

7
1 Second Breaths

• Change
• Give the recommended number of breaths, with
  each breath given over 1 second
• Why
• Lungs require less oxygen during CPR due to
  decreased blood flow and it is important to
  reduce interruptions to compressions
• Changed from - breaths over 1-2 seconds, the more
  the better

8
1 Second Breaths, continued

• Change
• Avoid delivering too many breaths or breaths
  that are too large or too forceful
• Why
• Too much volume in the chest cavity decreases
  blood return to the heart. Too forceful a
  breath can cause gastric distention and all it
  implies.
• Changed from - belief that more oxygen was better

9
1 Shock, Immediate CPR

• Change
• Deliver 1 shock, followed by the compression
  phase of CPR, continue 5 cycles
• Why
• There is almost a 40 second delay in analyzing
  the rhythm, delaying blood flow to vital organs
• V-fib is almost always eliminated in first shock
  so stacked shocks arent usually necessary.
• After shocking, it takes a few moments for a
  normal heart rhythm to return and more time for
  optimal blood flow, CPR can help increase the
  blood flow sooner
• Changed from - stacked shocks

10
Major Changes for EMS

• Definition of Child
• Tailor sequence for most likely cause
• Opening the Airway, Trauma Victim
• Check for adequate breathing
• Try a couple of times to get chest rise
• Excessive ventilation should not be performed

11
Major Changes for EMS, continued

• Emphasis on CPR children with HR lt60bpm
• Compressions at adequate rate and depth
• Hand placement change for pediatrics
• CompressionVentilation ratio changes
• With advanced airway no pause for breaths
• When 2 or more providers, rotate compressor role
  every 2 minutes

12
Definition of Child

• Change
• 1 year to onset of puberty
• Why
• Difficult to pick one anatomical or
  physiological
• characteristic that changes child to adult
• Changed from - 1-8 years

13
Tailor Sequence to Cause

• Change
• Adult phone first, get AED, provide CPR
• Infant/Child CPR for 2 min, phone 911, AED
  when available
• Any age- Hypoxic event, CPR for 2 min, phone
  911, AED when available
• Why
• Sudden collapse requires AED, Hypoxic event
  requires immediate CPR before activating 911
• Change not emphasized

14
Opening the Airway, Trauma Victim

• Change
• Head tilt chin lift unless c-spine injury is
  suspected
• Jaw thrust - if c-spine injury suspected, unless
  maneuver doesnt work, then head tilt chin lift
• Why
• Airway is a priority
• Changed from - Jaw thrust only

15
Check for Adequate breathing

• Change
• Adults -Check for adequate vs normal
  breathing, give 2 breaths
• Infant/Child check for presence/absence of
  breathing, give 2 breaths if not breathing
• Why
• No need to wait for apnea in adults
• Difficult to assess adequate but not normal
  breathing in pediatrics
• Changed from - check for adequate breathing for
  all victims

16
Chest Rise

• Change
• Try a couple of times to get adequate chest
  rise
• Why
• Asphyxia most common cause of cardiac arrest,
  need to try a couple of times to provide
  effective breaths
• Changed from - maneuver head to get optimal
  airway opening

17
Excessive Ventilation

• Change
• Give breath over 1 second, with just enough
  force to get chest rise
• Why
• Less ventilation than normal needed during CPR
• During CPR blood flow to lungs is 25 of normal,
  requiring less oxygen
• Hyperventilation decreases blood return to heart
  and can cause gastric distention
• Changed from - 1-2 seconds, large breaths

18
CPR for peds HRlt60bpm

• Change
• Despite adequate ventilatory support, HR
  remainslt60bpm, if so, begin CPR
• Why
• Bradycardia is a common terminal rhythm in
  children
• Change not emphasized

19
Adequate Rate and Depth

• Change
• Push Hard, Push Fast, allow recoil
• Limit interruptions to 10 seconds
• Why
• More effective chest compressions
• Increased cardiac output
• Better blood flow
• Changed from -no emphasis on recoil

20
Hand Placement

• Change
• Children heel of 1 or two hands
• Why
• Depending on childs size, better compressions
  were found to be done with 2 hands
• Change
• Infants - 2 thumb-encircling hands technique
• Why
• Produces higher coronary artery perfusion
  pressure
• Better depth and force of compression
• Generates higher systolic and diastolic
  pressures
• Changed from -1 hand in children and 2 fingers in
  infants

21
CompressionVentilation Ratio

• Change
• 1 rescuer 302
• 2 rescuer 152
• Why
• Simplify training
• Reduce interruptions
• Changed from - 51

22
Advanced Airway

• Change
• Once an advanced airway ( ET Tube, LMA,
  Combitube) is in place, continuous compressions
  at a rate of 100/minute
• Why
• No need to pause for breath, provides
  uninterrupted chest compressions
• Changed from - asynchronous compressions

23
Rotate Compressor Role

• Change
• Rotate compressor role every 2-3 cycles
• Why
• At the new rate compressors will tire more
  easily and may provide inadequate compressions
• Change not emphasized

24
Foreign Body Obstruction

• Change
• Intervention only applied to those with severe
  obstruction (poor air exchange, increased
  breathing difficulty, silent cough, cyanosis,
  inability to speak or breathe)
• Why not everyone requires intervention
• Change
• CPR instead of abdominal thrusts
• Why
• Previous system more complicated, CPR just as
  effective as abdominal thrusts
• Changed from - intervention if even mild
  symptoms, abdominal thrusts and back blows

25
Foreign Body Obstruction, continued

• Change
• In an unresponsive person, every attempt to
  deliver breaths should start with looking in the
  mouth and removing object if seen. Blind finger
  sweeps should not be performed
• Why
• Blind finger sweeps can result in damage to
  mouth or throat or to rescuers finger, and
  there is no evidence of effectiveness
• Changed from - blind finger sweeps in adults

26
What hasnt changed?

• EMS Providers
• BLS
• Checking for response
• Pulse check
• Rescue breathing without chest compressions
• Hand placement for adult chest compressions
• Compression rate
• Compression depth
• Ages used for infant BLS recommendations
• Defibrillation
• Initial dose for infants and children

27
NYS ProtocolsAdult Obstructed Airway

• ALWAYS Request ALS, do not delay transport,
  keep patient warm
• If pt is conscious and can breathe, cough or
  speak
• Do not interfere. Encourage coughing.
• If unable to dislodge obstruction with coughing
• Admin high flow O2, transport in sitting
  position,
• If pt is conscious with signs of severe airway
  obstruction
• Perform obstructed airway maneuvers
• If airway obstruction persists or pt becomes
  unconscious
• Begin CPR, transport
• If airway obstruction is cleared and pt resumes
  breathing
• Admin High flow O2, transport
• Changed from -continue obstructed airway
  maneuvers to CPR

28
NYS ProtocolsPediatric Obstructed Airway

• ALWAYS Request ALS, do not delay transport, keep
  patient warm, dont agitate child, transport
• If pt is conscious and can breathe, cough or
  speak
• Do not interfere, position of comfort,
  encourage coughing.
• If conscious but unable to breath, cough, speak
  or cry
• Perform obstructed airway maneuvers
• If pt is unconscious or becomes unconscious is
  not breathing
• Establish BLS airway, remove visible foreign
  body, CPR,
• If airway obstruction is cleared and/or
  establishment of chest rise
• Assess respiratory status, O2, assist
  respirations prn
• Changed from - continue obstructed airway
  maneuvers to CPR

29
NYS ProtocolsAdult Respiratory Arrest/Failure

• ALWAYS Request ALS, do not delay transport, keep
  patient warm
• Inadequate ventilatory status
• OPA (or NPA) High Flow O2 with BVM
• Rate 10-12/min, each over 1 second
• Tidal Volume adequate to make chest rise
• Changed from - without O2 700-1000ml over 2
  seconds, or with O2 400-600ml over 1-2 seconds

30
NYS ProtocolsPediatric Respiratory Arrest/Failure

• ALWAYS Request ALS, do not delay transport, keep
  patient warm
• Inadequate ventilatory status
• OPA (or NPA) High Flow O2 with BVM
• Rate 12-20/min, each over 1 second
• Tidal Volume adequate to make chest rise
• Changed from - without O2 450-500ml over 2
  seconds, or with O2 400-600ml over 1-2 seconds

31
NYS ProtocolsAdult Pediatric Cardiac Arrest

• ALWAYS DNR?, Request ALS, do not delay transport
• If apneic and pulseless
• If unwitnessed or EMS arrival 4 minutes since
  arrest
• CPR (5 cycles/2 min) prior to AED. Compressions
  152 (2 person)
• If witnessed or EMS arrival lt 4 minutes since
  arrest
• AED first, then CPR prn, Compressions 152 (2
  person)
• If secured advanced airway
• Respiratory rate 8-10/minute, no pause in
  compressions
• If one rescuer CPR compressions at 302
• Changed from - old compression ratio, AED first
  always

32
NYS ProtocolsAdult Pediatric Cardiac Arrest,
continued

• AED
• Monophasic- All shocks at 360j
• Biphasic All shocks at 120-200j
• Pediatric under age 8 use pediatric pads
• After all shocks CPR for 5 cycles/2min without
  checking pulse, rhythm check and/or defib.
• Pulse check after 5 cycles/2min or if pt appears
  to no longer be in cardiac arrest
• Max of 3 shocks on scene before transport
• Changed from - stacked shocks and joule settings,
  longer scene time

33
NYS ProtocolsEmergency Childbirth,
Resuscitation and Stabilization of the Newborn

• ALWAYS Request ALS, do not delay transport
• If newborn RR is absent or depressed (lt30bpm)
• ventilate with high flow O2 at 40-60bpm
• If newborns HR lt60 or does not increase above 60
  bpm
• after 30 seconds of assisted ventilations
• Add chest compressions
• at rate of 100/min and
• ratio of 302 for 1 rescuer, 152 for 2
  rescuers
• Changed from - RR 30-60, HR does not increase