The American Heart Association (AHA) constantly provides guidelines on caring for persons with heart disease based on research and scientific findings. The recent guidelines released in October 2020 base emphasis on the following areas:
- Improved algorithms and visual aids to guide resuscitation procedures.
- Significance of early CPR by lay rescuers.
- Significance of early epinephrine administration.
- Real-time audiovisual feedback in the delivery of high-quality CPR.
- Ongoing measurement of end-tidal carbon dioxide (ETCO2) blood pressure and during ACLS resuscitation.
- Patient care after the return of spontaneous circulation (ROSC).
- Care for cardiac arrest patients after discharge from hospital.
- Management of cardiac arrest in expectant mothers.
- Handling of opioid emergencies and early CPR by bystanders.
Adult Advanced Life Support
AHA findings suggest that less than 40 percent of adults receive CPR from a layperson. Out of these, only 12 percent have AED administered before the arrival of emergency medical services. Whenever resuscitation attempts fail, the rescuer should administer epinephrine. This provision also applies to victims with non-shockable rhythms.
The CPR procedure for adults entails the following steps:
Activate emergency response: When someone collapses and isn’t responsive, shout for help. If more than one person present, let one person dial emergency response (911) while the other starts CPR. Request for an AED device to be availed immediately.
Most often, cardiac arrest strikes without warning signs. The signs of cardiac arrest are loss of responsiveness and lack of normal breathing. When a victim collapses, it should take a health provider a few seconds to check for breathing and a pulse.
The AHA recognizes that it is difficult for non-medical professionals to detect a pulse. The risk of causing harm to the victim is very low. For this reason, if the victim doesn’t have a pulse or you aren’t sure, begin CPR immediately. Chest compressions do not harm the victim if they are not indeed experiencing cardiac arrest.
Provide high-quality CPR: According to the AHA 2020 guidelines, for a rescuer to give high-quality CPR, they should focus on the following:
- The required rate and depth of chest compressions. Locate the center of the chest and push hard enough to achieve the recommended depth. For adults, using the heels of your hand with fingers interlocked while children and infants require less pressure, as we will see later.
- The pressure and depth of chest compressions differ in adults and children. Rescuers should, therefore, apply the required pressure, which is enough to maintain blood circulation.
- Ensure there are minimum interruptions between the compressions. You should do the compressions interchanging whenever the compressor every two minutes or if fatigued. It will help if you avoid excessive ventilation. The ventilation should be at the rate of 2:30 (30 chest compressions should follow each two ventilation sessions).
Defibrillation: For better results, use the AED as soon as it is available. Research findings do not support the use of double defibrillation which makes use of two defibrillators simultaneously.
Pediatric CPR: The same findings apply for pediatric and adult CPR, which emphasize the provision of high-quality CPR. For high-quality CPR, AHA recommends:
- Minimized interruptions between the chest compressions
- Allowing the chest to recoil after every compression
- Avoiding excessive ventilation
- The right depth of chest compressions
In laypersons, the CPR process entails 30 chest compressions alternating with two rescue breaths. The rescuer must provide rescue breaths for infants and children in cardiac arrest. In hospitality, the respiratory rate should be 20 to 30 breaths per minute. It applies to infants with a pulse receiving rescue breathing. The same also applies to those with advanced airways.
If not able to provide rescue breaths, they should give chest compressions only (hands-only CPR). The rescuer should apply pressure on the infant’s sternum using two fingers, two thumbs, or the heel of one hand. The chest compressions should be 1.5inches or 4 centimeters deep.
For victims with non-shockable rhythms, early administration of epinephrine increases the chances of survival. AHA findings show that during using bag-mask ventilation, cricoid pressure will not lower regurgitation risk.
When giving CPR in-hospital cardiac arrest victims, bag-mask ventilation provides similar results as advanced airway interventions. After successful resuscitation, cardiac arrest victims require post-cardiac arrest care since it doesn’t return spontaneous circulation (ROSC) is not certain.
Post cardiac arrest care: Even after discharge from the hospital, cardiac arrest care is critical in cardiac arrest patients’ recovery. Victims often experience emotional, physical, and cognitive challenges. Thus, the patients require continued care and support, which can be in the former therapies and interventions.
Upon recovery, cardiac arrest patients need proper post-cardiac arrest syndrome management, which presents ischemia or reperfusion injury, myocardial dysfunction with low cardiac output, and brain dysfunction. The management of these conditions prevents the risk of secondary damage. Appropriate neuroprognosis is critical in proper caregiver guidance. Since cardiac arrest survivors are at a high risk of neurodevelopmental impairment, there is a need for early referral for a rehabilitation assessment.
In infants, the process involves continuous electroencephalography monitoring and targeted temperature management. The care also entails treating certain conditions such as hypercapnia/hypocapnia, hyperoxia/hypoxia, and hypotension.
Opioid poisoning: When attending to victims suspected of opioid poisoning, rescuers should aim at providing high-quality CPR. The use of naloxone is helpful in victims of opioid overuse who experience respiratory arrest. However, the drug is not effective for cardiac arrest victims; this makes the CPR procedure critical in these cases to keep the victims alive.
Steps for attending to opioid poisoning victims
- Check the victim for responsiveness.
- Yell for help and call emergency medical services.
- Get or request naloxone and an automated defibrillator.
- If the victim is breathing, reposition him or her and administer naloxone if necessary. Observe the victim until emergency medical services.
- If the victim is not breathing, start CPR immediately, and give naloxone. Use the AED if available.
- Continue performing CPR until medical help arrives.
- If the victim is breathing, provide a bag device mask or rescue breathing for health care providers, then administer naloxone.
- If the victim is not breathing, begin CPR immediately. Give naloxone if necessary, and then move on to the basic life support cardiac arrest algorithm.
Cardiac arrest in expectant women: In cases of expectant mothers, rescuers should inform the health providers in advance for in-hospital preparation. Expectant women are at a higher risk of hypoxia, and should be accorded priority with airway management and oxygenation. Fetal monitoring should be undertaken during maternal cardiac arrest as it is likely to interfere with the resuscitation. Temperature management is critical for expectant mothers who, after resuscitation, remain comatose. During temperature management, the fetus should be constantly monitored for potential complications such as bradycardia.
Debriefing for lay rescuers: Rescuers may experience posttraumatic stress and anxiety after providing or failing to provide basic life support—hospital-based healthcare providers, in particular, experience psychological and emotional effects after caring for cardiac arrest victims. AHA guidelines advise follow-up emotional support to hospital-based health workers, emergency responders, and lay rescuers after a cardiac arrest event. Health facilities should assess stressors associated with critically ill patients and conduct a review on team performance and the quality of services they offer.
Over 350,000 people experience out of hospital cardiac arrest annually in the United States with only 10% surviving. The survival rate in hospital cardiac arrest is 25%. The AHA believes more can be done to increase the rates of survival. It emphasizes the need for early high quality CPR and the use of epinephrine for unshockable rhythm. For cases suspected to be opioid overdose, naloxone is critical for respiratory arrest. More people need to acquire CPR skills and real time audio visual feedback is the best way to ensure high quality CPR.
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