Lifesaving Success Results in Updated AED/CPR Guidelines
Three scientific findings resulted in the new recommendation to deliver one shock followed by immediate CPR.
- By Glenn W. Laub, M.D., David Fritzsche
- Dec 01, 2006
SUDDEN cardiac arrest (SCA) remains a significant cause of death in America's
workplaces. OSHA attributes 13 percent of all workplace fatalities to SCA, and
health experts estimate that more than 400,000 individuals die of SCA in the
United States each year.
In
response to these stark statistics, automated external defibrillators and
trained AED/CPR rescue teams have been deployed in workplaces and public areas
across the country. Scientific evidence shows these efforts are making a
difference. Well-organized lay and first responder AED/CPR programs have
reported ventricular fibrillation (VF) SCA survival rates as high as 49 to 74
percent in some locations, according to the American Heart Association (AHA).
The
success of these deployments has been closely studied by resuscitation experts
and has resulted in the recently updated AHA Guidelines for Cardiopulmonary
Resuscitation (CPR) and Emergency Cardiovascular Care (ECC). To meet the
guidelines, AED manufacturers have made product upgrades available, some of
which are free and can be easily done in the field. As workplaces update their
AEDs to meet the new guidelines, they also should take a hard look at their
AED/CPR training programs and take appropriate action to meet the certification
guidelines. The AHA has outlined five major changes to the guidelines that affect
how AED/CPR training should be conducted:
- An emphasis on effective chest compressions.
- A single compression-to-ventilation ratio (30:2) for single rescuers.
- A recommendation that each rescue breath should be one second long and produce
a visible chest rise.
- A recommendation that a single defibrillating shock, followed by immediate CPR,
be used in cases of VF cardiac arrest.
- A recommendation to use AEDs on children 1 year of age and older.
1. Effective Chest Compressions
Effective
chest compressions improve blood flow, which increases the chance of survival.
The new guidelines encourage rescuers to "push hard and push fast" at
a rate of about 100 compressions per minute for all victims except newborns,
without interruption. The rescuer should allow the chest to recoil after each
compression.
Studies
of actual resuscitation show that half of chest compressions given by
professional rescuers are too shallow and that the compressions are interrupted
too often. The new guidelines strongly emphasize the importance of high-quality
chest compressions during CPR.
2. A 30:2 Compression-to-Ventilation Ratio for Single Rescuers
The
recommendation of 30 chest compressions followed by two one-second-long rescue
breaths simplifies CPR. Previously, the adult and child/infant ratios were
different. This guideline also reminds rescuers to deliver a longer series of
uninterrupted chest compressions. Compressions should be interrupted only for
rhythm checks and AED shock delivery. Pulse checking is not necessary until
organized rhythm is apparent after five cycles (about two minutes) of CPR.
3. One-Second-Long Breaths to Produce Visible Chest Rise
One-second
breaths provide enough ventilation while limiting interruptions to chest
compressions. Rescuers should take a normal, not a deep breath, before giving a
rescue breath.
Each
rescue breath should produce a visible chest rise. If the victim's chest
does not rise when the first rescue breath is given, the rescuer should perform
a head tilt-chin lift to open the airway before giving the second breath. The
new guidelines advise that lay rescuers should not use a jaw thrust to open a
victim's airway.
Longer
or more forceful rescue breaths actually can reduce blood flow because they
increase pressure in the chest and may result in gastric inflation and its
complications.
4. One Shock, Followed by CPR
Three
scientific findings resulted in the new recommendation to deliver one shock
followed by immediate CPR rather than the previously recommended "stacked"
sequence of up to three shocks before beginning chest compressions:
- AED
rhythm analysis after each of the three shocks was resulting in delays of 37
seconds or longer before the first post-shock compression was delivered. A
delay of this nature can be harmful to an SCA victim. The highest SCA survival
rates are associated with victims who are revived within a minute or two after
arrest; a delay of 30 seconds or longer, especially if the rescue team's
response is not immediate, can reduce the chances of survival or full recovery
with normal brain function.
- The
first shock of biphasic waveforms eliminates VF 85 percent of the time. Even in
cases where the first shock fails, CPR is likely to benefit the victim more
than another shock would.
- When
a shock eliminates VF, several minutes go by before normal heart rhythm returns
and the heart creates blood flow. Chest compressions deliver oxygen and other
sources of energy to the heart, assisting the heart to effectively pump blood
and return its rhythm to normal.
CPR
should continue for five cycles (about two minutes) before the heart rhythm is
checked. This new recommendation speaks to the high reliability of AEDs in
delivering a defibrillating shock, as well as to the importance of high-quality
CPR to increase the chances of survival.
5. AEDs Can Be Used for Children One Year of Age and Older
Some
AEDs have shown to be very accurate in recognizing pediatric shockable rhythms,
and some are equipped to deliver energy doses suitable for children. AEDs that
have been FDA-approved to deliver a "child" dose through a pediatric
pad are preferred for use in these situations.
If
your workplace serves children as customers or regularly has children on the
premises (because of an on-site day care program, for example), you should have
AEDs with pediatric capability.
When
delivering chest compressions to a child, use one or two hands and compress at
the nipple line; for infants, compress with two fingers on the breastbone just
below the nipple line.
New Guidelines Emphasize the Success and Importance of Lay Rescuer Programs
The
new guidelines emphasize the success and importance of lay rescuer programs,
including those where employees are trained as rescuers in the workplace. The
most vital element of a successful program is a planned and practiced
response, the guidelines state, usually with oversight by a health care
provider. Other important elements include the training of lay rescuers in CPR
and AED use, a link with the local EMS system, and an ongoing program of AED
maintenance and quality improvement.
These
programs, which feature AEDs and trained rescuers on site at the workplace, have
been successful primarily because they have been able to reduce the amount of
time it takes to reach and revive a SCA victim. Survival rates dramatically
increase when the victim is reached within three minutes. Studies show that
even the fastest off-site EMS teams are hard pressed to arrive in less than
five to 10 minutes.
"Turnkey" AED management programs assist workplaces to design, implement, and maintain a
comprehensive and highly functioning AED/CPR response on site. These programs
help businesses to:
- Choose
a high-quality, reliable, and easy-to-use AED. Features to look for include
self-testing, long battery life, and audible voice prompts that literally "talk"
to the user, providing clear instructions and confidence during a stressful
situation.
- Determine
how many AEDs are needed and where they should be located.
- Train
employee teams to provide AED/CPR rescue in the event of SCA.
- Accurately
track and maintain AEDs in proper working order.
- Keep
response teams up to date with all training requirements and certifications.
Turnkey
programs also facilitate medical oversight and a link to local EMS, including debriefings after SCA events that help to continually improve the quality of
the rescuer team's response and performance.
If You Don't Have an AED/CPR Program Yet
Despite
more than 400,000 SCA deaths in the United States each year, and despite the
proven success of AEDs and CPR in saving the lives of SCA victims, AED/CPR
programs have yet to become pervasive in workplaces and public areas. Most
workplaces do not have AEDs and, as a result, most SCA victims do not receive
the lifesaving benefits. Survival rates for out-of-hospital SCA average only
6.4 percent or less in the United States and Canada, according to the AHA.
However,
the high survival rates associated with well-organized AED/CPR programs has
driven a higher demand and expectation for these programs in workplaces and
public places. This expectation also is rising among customers of retail
businesses, hotels, restaurants, health clubs, and other enterprises with high
customer throughput.
As
a result, the liability tide has shifted in favor of having AEDs and personnel
trained in CPR readily available. The nation's courts have increasingly
acknowledged the availability of an AED as a "required standard of care"
for employees and citizens in public areas. These rulings have been in response
to lawsuits arising from situations when individuals have died because AEDs
were not available.
As
businesses consider the costs and benefits of AED deployment, they must factor
the risk of liability into the equation. Just one preventable SCA death can
cause a legal, public relations, and employee morale disaster for a business. A
well-organized AED/CPR response can turn an unfortunate event into a saved life--the
best return on investment imaginable.
This article appeared in the December 2006 issue of Occupational Health & Safety.
This article originally appeared in the December 2006 issue of Occupational Health & Safety.