Red Cross Releases Updated Resuscitation Guidelines

The American Red Cross has released updated guidelines for CPR, BLS, ALS, PALS, and NALS. The guidelines are available on the American Red Cross Guidelines Database. What I like about the updates from the American Red Cross is that if you're like me when I teach, then explaining the "Why" is important. These guidelines present not only the topic but, also the evidence and take away for each category. If you have any interest in these topics this is a must read!

The American Red Cross guidelines has 5 major Categories with multiple subcategories. They major categories are: BLS (Basic Life Support), ALS (Advanced Life Support), PALS (Pediatric Advanced Life Support), NALS (Neonatal Advanced Life Support, and Resuscitation Education Science.

Today we will address the BLS updated guidelines only. The updated BLS subcategories and a paraphrase of the ARC guideline conclusion are:

1. Early Access to AED's. AED for public access should not be locked in a cabinet and readily available. To achieve a balance between security needs and accessibility, some facilities will install AEDs in alarmed cabinets that can reduce the risk of theft or tampering while maintaining device accessibility. The audible alarm also alerts nearby personnel to the AED’s use, which can improve rapid response to an event. Strategic placement of AEDs in high-traffic, monitored areas can also reduce the risk of misuse and ensure the devices are quickly accessible during emergencies.

2. Optimization of Dispatcher-Assisted Recognition of Out-of-Hospital Cardiac Arrest. Dispatchers need additional training and support mechanisms to help direct and communicate by-standers through CPR steps and to help locate AEDs' in emergency CA events and application.

3. Assessment. Early assessment for life-threatening bleeding is performed with the check for responsiveness. The A-B-C mnemonic is a universal means to recall and perform assessment and initial action, including opening of the airway (A), checking for the presence or absence of normal breathing (B), and, for trained professionals, the simultaneous assessment for circulation (C) by a pulse check, or for lay responders, beginning compressions (C).

4. CPR Techniques and Process. This category addresses multiple topics ranging from chest compression ratios, pulse checks, timing checks to unintentional injury from CPR to persons not in cardiac arrest to termination of resuscitation rules. Basically, this topic can be summarized by presenting the "High Quality CPR" diagram which encompasses all of the topics addressed.

   
   

   

5. Defibrillation. This category covers defibrillator use, bra removal when using an AED, defibrillator electrode pad size and placement, pad size and placement on children, single versus stacked shock in pediatric cardiac arrest cases, AED use for infants and ultra-portable AEDs'. The take away here is that AED remain a very successful tool, even on infants.

   
   

   The guideline states, "Despite the lack of evidence in the ILCOR review to support the use of AEDs by lay responders for infants with out-of-hospital cardiac arrest, the American Red Cross Scientific Advisory Council review notes that there is no evidence to suggest harm from their use. The application of an AED may cause a slight pause in CPR, but that determinant is outweighed by the lifesaving benefit in both infants and children with shockable rhythms."

   
   

6. Drowning Process Resuscitation. Again, this category covers multiple subcategories. However, this category deals with drowning victims and the process of CPR with alternate ventilation techniques and considerations when giving CPR to a drowning victim. For me the ultimate takeaways from this category were:

   1. Start CPR with 2 breaths, not compressions.

   2. AED use should not be attempted while the drowning person is in water, and the chest should be dried off prior to use of an AED.

   3. For adults and children in cardiopulmonary arrest following drowning, supplemental high-flow and high-concentration oxygen should be provided, if available, with ventilations by responders trained in its use.

   4. Resuscitation from drowning may be performed on a boat if conditions are safe and there are adequately trained responders to assist.

7. Post-resuscitation Care. Debriefing. This category covers the topic of debriefing which falls into two (2) types. They are "Hot" and "Cold" debriefing. Takeaway is that each type of debriefing following a resuscitation should be conducted to reinforce positive actions and to identify system issues for improvement.

8. Special Circumstances. CPR in obese Adults and Children and Firefighter-Down CPR.

   1. In CPR on Obese persons, the takeaway for me was that providing cardiopulmonary resuscitation (CPR) on severely or morbidly obese individuals presents challenges due to anatomical and physiological differences. The increased adipose tissue in obese persons can impede the delivery of effective chest compressions. A recent scoping review explored the research evidence related to CPR in obese patients. The guideline conclusion is that:

      1. For adults, children and infants with obesity in cardiac arrest, use standard cardiopulmonary resuscitation (CPR) procedures. (Good practice statement).

      2. When delivering chest compressions to an obese adult in cardiac arrest, greater force may be needed to provide a compression depth of at least 2 inches deep. (Good practice statement).

      3. Team leaders should consider the need for more frequent personnel rotations when providing CPR to an obese adult. (Good practice statement).

   2. In Firefighter-Down CPR,

      1. It is reasonable to begin compression-only cardiopulmonary resuscitation (CPR) on an unresponsive firefighter following extrication from a dangerous environment and while beginning the removal of turnout gear and self-contained breathing apparatus (SCBA).

      2. The use of a specialized and coordinated team approach is recommended for the rapid and full removal of turnout gear and SCBA to allow for assessment of an unresponsive firefighter and, when indicated, initiation of compression-ventilation CPR and automated external defibrillator use.

9. Opioid-Associated Emergencies. This category discusses when opioids are suspected in a cardiac arrest, how should the delivery of naloxone be timed? Guideline conclusion is:

   1. Cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) use remain the first interventions for cardiac arrest in opioid overdose and should not be delayed or interrupted.

   2. For suspected cardiac arrest due to opioids, naloxone should be administered as soon as possible without disrupting or delaying CPR and AED use.

10. Management of Foreign Body Airway Obstruction. Foreign Body Airway Obstruction. This category addressed the question of, "Are any techniques for removing a foreign body obstruction more effective and safer than other techniques?" It addressed several FBAO care techniques of Back Blows/Slaps, Abdominal Thrusts, Chest Thrusts/Compressions, Finger Sweep, Magill Forceps, Suction-Based Airway Clearance Devices, and FBAO Removal by Bystanders. The guideline conclusion is that:

    1. Lay responders or healthcare professionals attempting to resolve a complete foreign body airway obstruction in a conscious adult or child should first provide up to 5 back blows until the foreign body is relieved or, if not relieved, transition to up to 5 abdominal and/or chest thrusts. If the foreign body is not relieved, they should continue with cycles of 5 back blows followed by 5 abdominal and/or chest thrusts until the obstruction is relieved.

    2. Lay responders or healthcare professionals attempting to resolve a complete foreign body airway obstruction in a conscious infant should first provide up to 5 back blows until the foreign body is relieved or, if not relieved, transition to up to 5 chest thrusts. If the foreign body is not relieved, they should continue with cycles of 5 back blows followed by 5 chest thrusts until the obstruction is relieved.

    3. Lay responders or healthcare professionals attempting to resolve a complete foreign body airway obstruction in an unconscious adult, child or infant should provide cycles of cardiopulmonary resuscitation (compressions and ventilations) with an additional step. After each set of compressions and before ventilations, open the mouth, look for an object, and if seen, remove it with a finger sweep. Never do a finger sweep if an object is not seen.

    4. Healthcare professionals with appropriate training may consider the use of Magill forceps to remove a foreign body obstructing the airway.

Wrapping up my takeaway from the new American Red Cross Resuscitation Guidelines. I would say that reviewing the diagram of "High Quality CPR Diagram" is the best overall takeaway. Read the guidelines and gain as much information as you can. Having the knowledge and ability to provide CPR may save a life. Maybe even someone very close and meaningful to You!

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