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Features: Staff Development Special: CE Article

A NEW BEAT FOR BLS AND ACLS GUIDELINES

Asselin, Marilyn E. RN,C, PhD; Cullen, H. Allethaire RNP, CS, MSN

Author Information
Nursing Management (Springhouse): February 2002 - Volume 33 - Issue 2 - p 31-38

Abstract

Follow this guide to lead a staff discussion on BLS and ACLS guidelines.

Find out about changes to the American Heart Association's revised life support guidelines.

Teaching Guide

Purpose: To improve nursing practice and the quality of care by providing a learning opportunity that enhances a participant's understanding of the new basic and advanced life support guidelines.

Program objectives:

1. Identify several revisions to ventilation and circulatory management during BLS and ACLS.

2. Describe the changes in drug treatment algorithms in ACLS.

3. Identify the personnel education and equipment needs that are required by the revisions to the BLS and ACLS guidelines.

BLS guidelines for adults

1. Calling emergency medical services

  • ventricular fibrillation
  • submersion, near drowning, or drug overdose

2. Fibrinolytic therapy in stroke patients

  • victim priority
  • screening tools
  • rapid transport
  • hospital notification

3. Preventing air from entering the stomach

  • complications
  • new guidelines

4. Assessing for signs of circulations

5. Compression-to-ventilation ratio

  • adults and children
  • two-rescuer CPR

6. Chest-compression-only CPR

7. Audio devices for CPR

8. Defibrillation

  • equipment and training
  • definition of early defibrillation

BLS guidelines for infants and children

  1. Concept of "phone fast"
  2. Carotid artery pulse checks over 1 year
  3. Assessing for other signs of circulation
  4. Rescue breathing
  5. Chest compressions

Simplified steps for adult ACLS

1. New universal/international ACLS algorithm and comprehensive cardiovascular care algorithm

-integrated steps of BLS, early defibrillation, and ACLS guidelines

-secondary role of adrenergic, antiarrhythmic agents, and buffer therapy

2. Ventilation

-confirmation of endotracheal tube placement

-tracheal intubation: reserved for personnel with proficient skills

-ventilatory tidal volume for patients not in cardiovascular collapse

3. Defibrillation

  • necessity of early defibrillation protocols
  • training for automated external defibrillators

4. Treatment of acute coronary syndromes

-12-lead electrocardiogram

-aspirin therapy

-pre-hospital fibrinolytic therapy

-angioplasty and intra-aortic balloon placement as an alternative to fibrinolytic therapy

-MI treatment: aspirin and betablockers

-patients requiring angiotensin-converting enzyme inhibitors

5. Stroke

  • rapid triage, transport, and treatment
  • indications for tissue plasminogen activator

6. Post-resuscitation care

  • hypothermic patients
  • avoiding hyperventilation except in cerebral herniation

7. Drug changes

8. Algorithm changes

  • reformatted and simplified algorithms
  • pulseless electrical activity
  • tachycardia algorithm
  • major revisions
  • three separate entities

Adapted from "What You Need to Know About the New BLS Guidelines," Nursing 2001, 31(3):48-50, and "What You Need to Know About the New ACLS Guidelines," Nursing 2001, 31(4):48-50.

The American Heart Association (AHA) has approved major revisions to basic life support (BLS) and advanced cardiac life support (ACLS) practice. Here's what staff members need to know.

BLS guidelines for adults

FIGURE Ventricular fibrillation is the most common cause of sudden, nontraumatic cardiac arrest in adults; survival decreases 7% to 10% for every minute that passes without defibrillation. If rescuers encounter an unresponsive adult, they should call the emergency medical service (EMS) before initiating cardiopulmonary resuscitation (CPR). In cases of submersion or near drowning, or cardiac arrest associated with trauma or drug over-doses, however, provide CPR for 1 minute before calling EMS. (See "Resuscitation interventions across the ages.")

Figure
Figure

Rescue breathing and bag-mask ventilation: Air entering the stomach instead of the lungs during resuscitation can cause serious complications, such as regurgitation, aspiration, and pneumonia. The new guidelines aim to reduce this risk by recommending that rescuers deliver mouth-to-mouth ventilations slowly, over 2 full seconds, with the least tidal volume needed to make the chest rise. Staff should take a deep breath before each ventilation so that their exhaled breath provides the victim with as much oxygen as possible.

If rescuers use a bag-mask device with an oxygen supplement of at least 40%, the AHA recommends delivering a smaller tidal volume (6 to 7 ml/kg) over 1 to 2 seconds. Because tidal volume proves difficult to assess, staff should measure the effectiveness of their efforts by assessing chest expansion and oxygen saturation values. The AHA considers alternative airway mechanisms, such as laryngeal mask airways and esophageal-tracheal devices, acceptable components of BLS if rescuers are educated to use them.

Pulse check: The new guidelines recommend that in addition to performing the standard pulse check, professional rescuers now assess for signs of circulation, including evidence of normal breathing, coughing, or any movement in response to the two rescue breaths given once rescuers have established an absence of breathing. For adult CPR, staff should perform chest compressions at a rate of 100 per minute, the same as for children. (Because they'll interrupt compressions for ventilations, they won't actually give 100 compressions in a minute.)

Chest compressions: The compression/ventilation ratio for two-rescuer CPR has also changed for a victim who isn't intubated. Previously, if a rescuer was alone, he or she would perform 15 compressions, then give two ventilations and continue this 15:2 rhythm until joined by a second rescuer. Then the pair would switch to a 5:1 compression/ventilation ratio. The AHA now recommends continuing the 15:2 ratio for two-rescuer CPR. Rescuers should remember to pause 2 seconds for each ventilation; once they secure the airway, they should switch to a 5:1 ratio.

Another change involves chest-compression-only CPR: Because studies show that chest compressions without ventilations provide significantly better outcomes than no CPR at all, the guidelines recommend that rescuers perform chest-compression-only CPR if they are unable or unwilling to perform rescue breathing.

The AHA also recommends audio devices that talk the rescuer through the steps of learning CPR. These devices, which prompt the learner and provide consistent, repetitive practice, improve learning and skills retention.

In-hospital defibrillation: Research indicates that in the hospital, the average length of time from collapse to first defibrillation shock can be 5 to 10 minutes-an unacceptable delay. The new guidelines state that all health care providers who may need to perform CPR should receive equipment, education, and authorization to perform defibrillation. The AHA defines "early defibrillation" in a hospital or ambulatory care facility as a collapse-to-shock interval of less than 3 minutes, so expect to see more defibrillation equipment surfacing in your facility and more trained personnel using it.

BLS for infants and children

Phone fast vs. phone first: The concept of "phone fast" still applies in most instances involving children: Rescuers should perform CPR for 1 minute before activating EMS. The new exception: If the child is at high risk for cardiac arrhythmias and is in cardiac arrest, rescuers should phone first to activate EMS and get the defibrillator on the way, then begin CPR.

Pulse check: Rescuers should check for a pulse in cases of suspected cardiac arrest, using the carotid artery for the pulse check unless the child is under 1 year old in which case the rescuer then uses the brachial artery. They should also assess for other signs of circulation (normal breathing, coughing, movement).

Rescue breathing and bag-mask ventilation: If the rescuer can't cover the infant's nose and mouth to deliver rescue breaths, the AHA recognizes mouth-to-nose breathing as an acceptable alternative. All health care providers should receive instruction in the use of bag-mask devices for infants and children.

Chest compressions: The AHA now prefers the two-thumb/encircling-hands chest compressions to the two-finger technique previously used. Because the two-thumb method doesn't provide the rescuer an opportunity to deliver ventilations effectively, reserve its use only for when two trained health care providers are available.

Simplified steps for adult ACLS

A new universal/international ACLS algorithm and a comprehensive emergency cardiovascular care algorithm simplify the information for adult ACLS. These integrate the steps of BLS, early defibrillation, and ACLS guidelines. The AHA relegates adrenergic and antiarrhythmic agents and buffer therapy to secondary roles regardless of whether the patient is in ventricular fibrillation (VF). Key changes target:

Ventilation. Many experts feel that the most important new recommendation is the confirmation of endotracheal (ET) tube placement by methods other than physical assessment alone-a recommendation based more on a care philosophy than on strict scientific evidence.

The primary method of confirming ET tube placement is chest auscultation. But because clinical signs aren't always reliable, the guidelines recommend using secondary methods for confirming placement, including esophageal detector devices, qualitative end-tidal CO2 indicators, and capnographic waveform monitors. Staff should perform a secondary confirmation of tube placement immediately after intubation, during or after any time they move the patient, and during transport. Because properly placed ET tubes can easily dislodge during ACLS procedures and long transports, caregivers should secure the tube with tape and vigilantly monitor its position.

Only personnel with tracheal intubation education and proficient skill should perform this procedure. A non-evidence-based guideline suggests reserving the procedure for those with a minimum of 6 to 12 in-field intubations per year. If caregivers don't have this experience, they should use noninvasive techniques, such as bag-mask devices or alternative airways.

Conference experts recommend reducing the ventilatory tidal volume for patients not in cardiovascular collapse to 6 to 7 ml/kg over 1 1/2 to 2 seconds-similar to what was noted for rescue breathing in BLS. Their concern was that higher volumes increase the risk of gastric inflation without significantly improving blood oxygenation. The AHA recommends the "chest rise" as a sign of adequate ventilation. Because of the dangers of hypoxia and hypercapnia with these lowered tidal volumes, rescuers should titrate supplemental oxygen according to oxygen saturation levels. TABLE

Table
Table:
Resuscitation interventions across the ages

Defibrillation. All hospitals must establish protocols to make early defibrillation available in all patient-care areas. All health care providers expected to perform cardiopulmonary resuscitation should receive education in the use of automated external defibrillators and remain competent in their usage. The new recommendations call for a goal of 3 minutes or less from collapse to shock in all hospital areas and ambulatory care facilities and biphasic defibrillation as a Class IIa recommendation.

Treatment of acute coronary syndromes (ACS). Here's an overview of the guideline changes regarding ACS treatment:

1. All ACLS providers who manage ACS patients should stand ready to perform a 12-lead electrocardiogram (ECG) in the field. A prehospital 12-lead ECG can reduce time to diagnosis and treatment leading to reperfusion of the affected myocardium.

2. Use aspirin (100 to 325 mg) immediately for any patient with ACS symptoms (unless allergic). Rescuers should opt for the chewable form because it's absorbed faster.

3. When the time to transport a patient from home to hospital is prolonged, rescuers should use prehospital fibrinolytic therapy, which is also appropriate if more than 1 hour passes between the onset of chest pain and the notification of ACLS providers, or from the arrival of ACLS providers to the patient's arrival at the hospital.

4. If "door-to-balloon" time is less than 90 minutes, facilities with experienced providers should consider angioplasty and intra-aortic balloon placement as an alternative to fibrinolytic therapy. Transport patients ineligible for fibrinolytics because of a high risk of intracranial bleeding to these centers. Rescuers should also consider angioplasty and intra-aortic balloon insertion for patients with large anterior infarctions, systolic blood pressure less than 100 mm Hg, tachycardia greater than 100 beats/minute, or crackles one-third of the way up from the lung bases. 5. Unless otherwise indicated, caregivers should administer aspirin and beta-blockers to all patients with acute myocardial infarction (MI). Patients who aren't hypotensive with large anterior infarctions, left ventricular dysfunction, and ejection fractions less than 40% will also need angiotensin-converting enzyme inhibitors early in their care.

Stroke. Patients with stroke symptoms need to be triaged, transported, and treated as rapidly as patients experiencing an acute MI. Fibrinolytic therapy can reduce neurologic damage and maximize recovery opportunities for the 75% of stroke patients who have an ischemic event. Fibrinolytic therapy must occur within 3 hours of symptom onset, so rapid recognition and intervention are key. Because of this, EMS personnel should give potential stroke victims the same priority as patients suspected of having an acute myocardial infarction (MI). The guidelines call for use of stroke screening tools and rapid transport to hospitals that provide fibrinolytic therapy within 1 hour of the patient's arrival. The guidelines also recommend that EMS personnel notify the hospital that a potential stroke victim is en route to facilitate access to the "clot busters." Once at the facility, rescuers will rule out hemorrhagic stroke with a computed tomography scan, then use an intravenous recombinant tissue plasminogen activator (rtPA) to improve neurologic outcome. The AHA doesn't recommend giving rtPA more than 3 hours after symptom onset.

Postresuscitation care. Instruct staff to not actively rewarm mildly hypothermic patients after resuscitation. They should quickly treat a febrile patient to bring his body temperature back to normal. They should also avoid hyperventilation after a successful resuscitation effort, as evidence suggests it may be harmful. Mechanically ventilated patients' ventilatory indicators should remain in the normal range, with one exception: Patients with evidence of cerebral herniation after resuscitation may benefit from short periods of hyperventilation. Hemiation may occur because hypoxia increases intracranial pressure.

Drug changes

Another new approach in the recommendations: only one antiarrhythmic per patient, except for rare exceptions. Antiarrhythmics may actually have a proarrhythmic effect and combining them can worsen the patient's condition.

Evidence suggests that lidocaine and epinephrine, the "old reliables" of ACLS, may not be so reliable after all. Here's a summary of how and when staff should use these and other common antiarrhythmics:

Lidocaine. Evidence supporting the usefulness of lidocaine for shock-refractory VF and pulseless ventricular tachycardia (VT) is poor; no study shows that lidocaine is effective in treating cardiac arrest in humans. Lidocaine can suppress VF and VT associated with acute myocardial ischemia and infarction once they occur, but using it prophylactically is contraindicated. Because the evidence supporting lidocaine's efficacy is lacking, other antiarrhythmics, such as amiodarone, emerge as better choices.

Amiodarone. Scientific evidence strongly supports using amiodarone instead of lidocaine, although this point is covered only in the notes of the VF/pulseless VT algorithm. One highly respected arrest study provided evidence that amiodarone outperforms other antiarrhythmics, and the AHA recommends it as a first-line antiarrhythmic for shock-refractory VT/VF. The AHA also recommends amiodarone ahead of lidocaine and adenosine as the initial treatment for wide-complex tachycardia in hemodynamically stable patients; procainamide before lidocaine and adenosine for these patients; and amiodarone and sotalol for the treatment of stable monomorphic and polymorphic VT.

Epinephrine. The AHA no longer recommends high-dose epinephrine (0.1 mg/kg) for treating cardiac arrest because of the lack of evidence that it improves survival. Also, patients who received high-dose epinephrine for cardiac arrest and survived have more complications after resuscitation than those who received a standard dose. As with lidocaine, the evidence supporting epinephrine use in cardiac arrest is poor, so vasopressin is now the recommended drug.

Vasopressin (arginine vasopressin). In an important new recommendation, the committee has identified vasopressin, an adrenergic alternative to epinephrine, for promoting the return of spontaneous circulation after cardiac arrest. Vasopressin, a naturally occurring antidiuretic hormone, offers powerful vasoconstrictor effects when used at doses much higher than normally found in the body. Its positive effects duplicate those of epinephrine, but with fewer or less-severe adverse effects. Rescuers should administer vasopressin as a one-time dose of 40 units. Compare its 10- to 20-minute half-life with the 3- to 5-minute half-life of epinephrine, and you'll see another reason why vasopressin now finds favor in resuscitation efforts.

Magnesium. The AHA only recommends this drug for the treatment of hypomagnesemia and torsades de pointes.

Bretylium. Although still considered an acceptable drug, the AHA no longer recommends bretylium for VT/pulseless VF. In fact, the AHA removed it from ACLS treatment algorithms and guidelines because of its high incidence of adverse reactions and the availability of safer drugs.

Algorithm changes

The algorithms for pulseless electrical activity, asystole, and bradycardia have been reformatted to use the primary and secondary survey frameworks, but the management arms, including drug regimens, haven't changed. You'll find these algorithms simplified because the primary and secondary surveys clearly list their steps. However, the tachycardia algorithm, always a bit complicated, has undergone major revisions and now is presented as three separate entities: an overview algorithm, one for narrow-complex supraventricular tachycardia, and one for stable VT. These new algorithms force us to look at specific diagnoses and consider cardiac functional status as defined by ejection fraction.

In rhythm

Based on the latest research, the new BLS and ACLS guidelines provide a wealth of information and resuscitation strategies designed to save lives. Ensure that staff members stand ready to efficiently implement the guidelines as soon as your facility adopts them.

Bibliography

American Heart Association in Collaboration with the International Liaison Committee on Resuscitation: "Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: An International Consensus on Science," Circulation. 102(Suppl. I), August 22, 2000.
    Kidwell, C., et al.: "Identifying Stroke in the Field; Prospective Validation of the Los Angeles Prehospital Stroke Screen (LAPSS)," Stroke. 31(1):71-76, February 2000.
    Kudenchuk, P., et al.: "Amiodarone for Resuscitation After Out-of-Hospital Cardiac Arrest due to Ventricular Fibrillation." The New England Journal of Medicine. 341(12):871-878, September 16, 1999.

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    CE TEST 1.5 ANCC/AACN CONTACT HOURS

    A NEW BEAT FOR BLS AND ACLS GUIDELINES

    PURPOSE: To improve nursing practice and the quality of care by providing a learning opportunity that enhances a participant's understanding of the new basic and advanced life support guidelines.

    PARTICIPANT OBJECTIVES: After reading the article and taking this test, you should be able to: 1. Identify several revisions to ventilation and circulatory management during BLS and ACLS. 2. Describe the changes in drug treatment algorithms in ACLS. 3. Identify the personnel education and equipment needs that the revisions to the BLS and ACLS guidelines require.

    1. If rescuers encounter an unresponsive adult, they should

    1. call emergency medical service (EMS) before initiating cardiopulmonary resuscitation (CPR).

    2. provide CPR for 1 minute before calling EMS.

    3. perform 15 compressions, then give 2 ventilations, then call EMS.

    4. establish an absence of breathing and circulation, then call EMS.

    2. The risk of air entering the stomach may be reduced by

    1. delivering supplemental oxygen via a bag-mask device using a volume of 6 to 12 ml/kg.

    2. delivering supplemental oxygen via a bag-mask device over 3 seconds.

    3. delivering mouth-to mouth ventilations with just enough volume to make the chest rise.

    4. delivering mouth-to mouth ventilations over 3 seconds.

    3. Once caregivers have established an absence of breathing in response to 2 rescue breaths they should

    1. provide 1 more breath.

    2. check for coughing.

    3. place an esophageal-tracheal device.

    4. consider a laryngeal mask airway.

    4. Switching from a one to a two-rescuer CPR includes an immediate

    1. no pause between ventilations.

    2. 1-second pause between ventilations.

    3. switching to a 5:1 compression/ventilation ratio.

    4. maintaining a 15:2 compression/ventilation ratio.

    5. Which of the following statements is true?

    1. Caregivers should perform chest-compressions-only CPR if they are unable to perform rescue breathing.

    2. The acceptable time from collapse to first defibrillation shock in the hospital is 5 to 10 minutes.

    3. Health care providers learning ACLS learn defibrillation as opposed to those learning CPR.

    4. Care givers should begin CPR, then phone EMS, if a child is at high risk for cardiac arrhythmias.

    6. Infant CPR

    1. excludes mouth-to-nose breathing.

    2. includes two-thumb/encircling-hands chest compressions.

    3. includes performing 2 minutes of CPR before activating EMS.

    4. includes carotid artery palpation for pulse check.

    7. A secondary method of confirming endotracheal (ET) tube placement is

    1. esophageal-tracheal devices.

    2. tracheal detector devices.

    3. end-tidal O2 indicators.

    4. capnographic waveform monitors.

    8. Which of the following statements is true regarding ventilation?

    1. Tracheal intubation should be limited to personnel with 6 to 7 in-field intubations per year.

    2. Tidal volumes higher than 6 to 7 ml/kg significantly improve blood oxygenation.

    3. The "chest rise" is a sign of adequate ventilation.

    4. Supplemental oxygen should be titrated according to CO2 levels.

    9. Treatment of acute coronary syndromes include

    1. a 12-lead electrocardiogram in the field.

    2. one chewable aspirin (30 mg).

    3. pre-hospital fibrinolytic if more than 2 hours pass between the onset of chest pain and the notification of ACLS providers.

    4. angiotension-converting enzyme inhibitors later in the care for patients with left ventricular dysfunction.

    10. What is the number of hours that fibrinolytic therapy for stroke must occur within, in order to reduce neurologic damage and maximize recovery?

    1. 1

    2. 2

    3. 3

    4. 4

    11. Which of the following statements is true?

    1. Give recombinant tissue plasminogen activator (rtPA) within 4 hours after the onset of stroke symptoms.

    2. Perform a computed tomography scan prior to administering rtPA.

    3. Actively rewarm mildly hypothermic patients after resuscitation.

    4. Provide long periods of hyperventilation to patients with evidence of cerebral herniation after resuscitation.

    12. The medication recommended as a first-line antiarrhythmic is

    1. lidocaine.

    2. amiodarone.

    3. procainamide.

    4. sotolol.

    13. Which of the following statements is true?

    1. The recommended epinephrine dose is 0.1mg/kg.

    2. The recommended vasopressin dose is 40 units.

    3. The half-life of epinephrine is 10 minutes.

    4. Vasopressin is associated with more adverse effects than epinephrine.

    14. Administer magnesium to treat

    1. hypotension.

    2. ventricular fibrillation.

    3. stable monomorphic ventricular tachycardia (VT).

    4. torsades de pointes.

    15. Bretylium

    1. is no longer recommended for VT by the American Heart Association.

    2. has a low incidence of adverse reactions.

    3. promotes the return of spontaneous circulation after cardiac arrest.

    4. is recommended to prophylactically treat VT in the setting of an acute myocardial infarction.

    16. The new ACLS guidelines

    1. include new drug regimens for treating pulseless electrical activity, asystole, and bradycardia.

    2. discourage the attempt of using ejection fraction to guide care.

    3. force us to look at specific diagnoses.

    4. include one tachycardia algorithm as opposed to three separate entities.

    FORM

    Figure
    Figure
    © 2002 by Lippincott Williams & Wilkins, Inc.