Gearing Up for the New Standards

Companies provide insight on how they’re working to assist customers in meeting the 2010 AHA CPR Guidelines


 
 

From the Evolution in Resuscitation Issue


Meeting the AHA’s 2010 CPR Guidelines will not only require changes in protocols; for some EMS agencies and systems, it will require changes in equipment or in how existing equipment is used.

Cutting-edge technology has been, and will continue to be, an essential part of the quest for high-quality CPR, helping agencies assess the effectiveness of their personnel’s CPR techniques and providing ways to improve effectiveness.

Accordingly, we asked the sponsors of this supplement to provide a few words about how they are preparing to help their customers achieve compliance with the 2010 CPR Guidelines.

Laerdal Medical
Every life saved through CPR is a testimony to how fortunate we are that medical science has continued to refine this single basic life-saving intervention.

EMS caregivers respond to nearly 300,000 out-of-hospital cardiac arrests annually in the U.S., according to the AHA.  And, as EMS begins to adopt the new AHA Guidelines, Laerdal is poised to help.

Since CPR was first introduced 50 years ago, the same time that Laerdal launched its now famous Resusci  Anne training manikin, significant research has been done to assess the effectiveness of CPR and its training methodology.  The results show that:
• The quality of CPR has a direct impact on patient outcomes.
• Caregivers, on the whole, do not perform CPR within established guidelines for compression rate, depth, hands-off duration for ventilation, and ventilation rates.
• Lastly, and as alarming, CPR skill levels are shown to drop off immediately after training and continue to decline without skill reinforcement.

Laerdal’s response to the need for a higher quality of CPR is its complete line of training solutions designed to suit all program needs and budgets. Whether the training objective is for basic CPR skills practice or for simulation solutions necessary to rehearse new AHA Guidelines as a team, Laerdal offers practical solutions that support success. 

Laerdal’s popular Resusci Anne, Resusci Junior, and Resusci Baby manikins offer optional measurement and feedback systems.  These features provide realistic patient simulation and improve trainee skills through:
• Measured physical performance;
• Audiovisual feedback; and
• Post-event debriefing.

More basic and economical alternatives are Laerdal’s Little Anne, Little Junior, and Baby Anne manikins. These represent budget-stretching options that still provide effective CPR training without compromising realism, quality or durability.

And, still two other alternatives are the HeartCode BLS and the Family and Friends CPR Anytime solutions developed in our partnership with the AHA. Both offer maximum affordability, anytime-access, and the benefit of self-directed learning.
Laerdal is committed to providing training solutions that are compliant with the new AHA Guidelines as they apply to both CPR and ECC.

Measured, realistic, quality training leads to quality performance. In short, perfect practice makes perfect. And, given the AHA’s protocol change to the “Compression-Airway-Breathing” (C-A-B) sequence, the new standard for compressions and ventilations, perfect practice for all EMS providers is absolutely essential. 

Laerdal has a longstanding relationship with, and commitment to, EMS providers everywhere. We appreciate all that the EMS community does in its preparedness to provide CPR.  And, our part in bringing CPR education and training solutions to the EMS community is one of the most satisfying ways in which we are able to fulfill our mission of “Helping Save Lives.”

For a complete listing of Laerdal CPR Training and Simulation Solutions, please go to www.laerdal.com.

Michigan Instruments, Inc.
The new AHA CPR Guidelines address mechanical CPR devices specifically in Part 7 CPR: Techniques and Devices.

“Mechanical piston devices” consist of a compressed gas or electric-powered plunger mounted on a backboard used to depress the sternum. Three studies cited in the Guidelines (Dickinson et al., 1998; McDonald, 1982; and Ward et al., 1993) demonstrate improved mean arterial pressure and end-tidal CO2 during adult cardiac arrest resuscitation using Michigan Instruments, Inc. (MII) piston Thumpers. References cited indicate the addition of a suction cup to the mechanical piston device using FDA-required limited upward force has not demonstrated benefit over manual CPR.

The Guidelines state mechanical piston devices can be considered for use by properly trained personnel in specific settings for treatment of adult cardiac arrest in circumstances that make manual resuscitation difficult.

Since 1964, MII customers have identified difficult manual CPR circumstances, including:
• Limited physically fit persons available;
• While moving the patient on a spineboard, stretcher, sling, etc;
• While in moving emergency vehicles;
• For large patients;
• When rescuers become fatigued; and
• For long-term CPR, e.g. hypothermia, drug overdose, etc.

Recent studies demonstrate that manual CPR that follows the AHA 2005 CPR Guidelines improves outcomes somewhat (Olasveengen et al., 2009), but studies also show that manual CPR often has serious quality problems, including excessive hands-off fraction and technique drift (Wik et al., 2005; Sugerman et al., 2009). In addition, EMS staff often over-ventilate, and that can reduce survival (Aufderheide et al., 2004).

New requirements for CPR include:
• At least 2" (5 cm) compression depth for adults and children and 1.5" (4 cm) for infants;
• Compression rate of at least 100/min;
• 50% compression;
• Complete recoil;
• Oxygen inhalation phase of one second;
• 30:2 compression-to-ventilation or continuous compressions with 8 to 10 oxygen ventilations/min.; and
• Hands-off time less than 5 seconds.

Life-Stat mechanical piston CPR was introduced in February 2008 as an electronically controlled oxygen-powered system with a built-in automated transport ventilator (ATV). The Life-Stat can deliver 2 inches and more compression depth up to 3.2 inches—always with complete recoil. The compression depth can also be set precisely to 1.5 inches. Adjustable tidal volume pressure-relief oxygen ventilation is coordinated with compressions using a one-second inhalation phase in either 30:2 or continuous compression modes and will not over-ventilate.

New rapid deployment and setup methods of the Life-Stat at the patient site include a one-time transfer from manual to mechanical CPR in less than 5 seconds. Thereafter, Life-Stat utilization doesn’t require any interruption.  As such, the current Life-Stat is fully compliant with the new 2010 AHA CPR:  Techniques and Devices Guidelines.

Philips Healthcare
Philips HeartStart ALS monitor/defibrillators and AEDs support the 2010 Guidelines now. 

The 2010 Guidelines signal the importance of coordinating multiple therapies to help save lives from cardiac events, emphasizing high-quality CPR with minimal interruptions, chest compressions for untrained rescuers, current-based defibrillation, effective CO2 monitoring and post-resuscitation care. 

All Philips MRx and XL monitor/defibrillators support the energy recommendations for defibrillation and synchronized cardioversion. The CO2  monitoring functionality on the HeartStart MRx meets the new Class 1 recommendation for the use of continuous waveform capnography, which is recommended, in addition to clinical assessment, as the most reliable method of confirming and monitoring correct placement of an endotracheal tube.

The Philips Q-CPR Measurement and Feedback tool can be used to promote a “culture of high-quality resuscitation” by providing the measurements needed to implement the recommended assessment of CPR performance. It can help users implement a Guidelines-compliant CPR protocol and help reduce the likelihood of hyperventilation during resuscitation.

The measurements provided on the CPR meter and the MRx display allow users to fine-tune their CPR techniques based on the new Guidelines for compression depth and rate. Based on the refinements to the compression depth and rate targets in the 2010 Guidelines, Philips is planning to fine-tune the feedback provided by the next-generation Q-CPR tool with the CPR meter. We’re working with our Alliance Partner, Laerdal, and will provide an update to customers through our website as soon as possible.

Philips HeartStart OnSite/HS1, FRx, and FR2+ AEDs also support the 2010 Guidelines, including the recommendations for defibrillation electrical therapy. This applies to newly shipped devices, as well as customers’ deployed Guidelines 2005 devices.

The HeartStart HS1 and FRx CPR Coaching can be configured to support either of the two recognized CPR protocols: the chest compression-ventilation sequence of 30:2 or the compressions-only recommendation for lay responders who are untrained, unwilling or unable to provide breaths. In two different peer-reviewed studies, Philips led in getting responders to perform CPR vs. the other AEDs studied.

Philips is dedicated to improving outcomes through evidence-based research and innovation in therapy, response protocol orchestration, human factors and product design. We continue to be aligned with the expert recommendations from these international thought leaders in resuscitation and emergency cardiac care. 

Physio-Control, Inc.
Physio-Control is committed to providing science-driven, innovative solutions that improve emergency care. We are pleased that Physio-Control product development directions are in line with the directions we see coming from the science.  Additionally, our review indicates that all current Physio-Control manufactured and distributed products are consistent with the 2010 AHA and ERC Guidelines.

Key areas to highlight from the Guidelines:
• CPR quality is emphasized, particularly fewer interruptions in chest compressions and post-event review to improve CPR quality. Physio-Control is focused on post-event review and targeted feedback to resuscitation team members to improve CPR performance. Available Physio-Control solutions, such as CPR Metronome with chest compression and ventilation guidance and CODE-STAT Data Review Software with Advanced CPR Analytics software, are consistent with the Guidelines.
• The new Guidelines may make it more challenging for healthcare providers to perform high-quality CPR for extended periods of time, leading more cardiac arrest response teams to consider mechanical CPR systems such as LUCAS 2 chest-compression system to provide high-quality chest compressions. 
• Implementing a quality improvement system for resuscitation performance, including measurement and benchmarking, is also recommended. CODE-STAT Data Review Software with Advanced CPR Analytics is a post-event feedback tool that enables EMS to review CPR statistics and provide training and feedback where it’s needed.
• The use of quantitative waveform capnography for airway management in adults, and the use of capnography and other physiologic monitoring, are also recommended to monitor and optimize quality of CPR and detect return of spontaneous circulation. Both the LIFEPAK 12 and 15 monitors provide continuous waveform capnography.
• Several strategies are emphasized for the treatment of chest pain patients, including systems of care for patients with STEMI, performance of prehospital 12-lead ECGs with transmission or interpretation by EMS providers, and triage to hospitals capable of performing PCI. The LIFEPAK 15 monitor/defibrillator incorporates ST-Segment Trend monitoring for on-scene support, and seamless transmission through the LIFENET System lets EMS securely share 12-lead ECG data with others who are critical to timely patient treatment.
• Development of AED programs is encouraged. Having more AEDs, such as the fully automated LIFEPAK CR Plus AED, available in community settings is critical to helping improve survival rates from SCA.
• Regarding biphasic defibrillation energy, the Guidelines again state that if a first defibrillation shock is not successful and the device is capable of delivering higher energy shocks, it’s reasonable to increase the energy for subsequent shocks. Importantly, the 2010 Guidelines  state that no human studies have demonstrated evidence of harm from any biphasic waveform up to 360J. Physio-Control only offers LIFEPAK devices with a full range of energy. We believe the capacity for 360J gives patients a better opportunity for a better outcome.  

For more information, please visit www.physio-control.com.

Vidacare
The 2010 AHA Guidelines recognize that intraosseous (IO) access provides quick access to the vascular space through the medullary cavity of the bone, which acts as a non-collapsible vein.  All resuscitation drugs normally administered through an intravenous line can be rapidly and safely administered through an IO line. 

Research studies have shown that medications administered through the proximal humerus via the IO route reach the heart at the same rate as drugs given through a central line—even during cardiac arrest.(1,2)

IO access has been adopted by EMS agencies and emergency departments for early use during cardiac arrest and resuscitation. The new AHA Guidelines serve to reinforce that practice.

Vidacare’s innovative technology platform has dissolved a primary barrier in the field of intraosseous medicine—easy and safe access to the intraosseous space. With a precise, controlled insertion, the EZ-IO provides immediate vascular access to the central circulation within seconds, delivering medications, intravenous fluids and blood products to adult and pediatric patients alike. 

Vidacare is continually innovating to provide clinicians the latest technological improvements in intraosseous access. Vidacare recently introduced new needle packaging to help expedite the use of EZ-IO during cardiac arrests, as well as recommendations for EZ-IO placement in the humerus to facilitate the prehospital therapeutic hypothermia (TH) cooling process.

The EZ-IO Intraosseous Infusion System provides immediate vascular access for the delivery of essential medications and fluids, and is used by 90 percent of U.S. advanced life support ambulances and over half of U.S. emergency departments, as well as the U.S. military.

1. Hoskins S, Kramer G, Stephens C, et al. Efficacy of epinephrine delivery via the intraosseous humeral head route during CPR. Circulation. 2006;114:II–1204.
2. Neuhaus D, Weiss M, Engelhardt T, et al. Semi-elective intraosseous infusion after failed intravenous access in pediatric anesthesia. Pediatr Anes. 2010;20:168–171.

ZOLL Medical Corporation
ZOLL Medical Corporation is “Guidelines-ready,” with a proven track record of offering ground-breaking technologies that help rescuers meet or exceed AHA recommendations for CPR and beyond.

Integral to ZOLL’s leadership position is a history of anticipating Guidelines recommendations and proactively developing technologies that support their implementation. The company introduced Real CPR Help in 2002—three years before Guidelines 2005 emphasized the critically important role of high-quality CPR. Real CPR Help provides a comprehensive set of visual and audible prompts to maximize effectiveness of depth as well as rate.

Further, ZOLL is the only company offering See-Thru CPR, a breakthrough that minimizes pausing by filtering out compression artifact, allowing the rescuer to see organized underlying rhythms without stopping compressions.

This practice of proactive innovation continues in 2010. The latest Guidelines now call for compression depth of at least 2 inches, and ZOLL will help meet this requirement by offering a quantitative depth readout as part of the upcoming “CPR Dashboard.”* A simple software change will also modify the currently available depth indicators to meet the new standard, which cannot be done with metronome-only systems.  A release indicator* will also be added, further matching recommendations for complete chest recoil.

The new Guidelines also state that providers must ensure efficient coordination between CPR and shock delivery.  A new ZOLL technology* will do this and help minimize interruptions by automatically charging the defibrillator during compressions. After two minutes of CPR as indicated by a CPR timer, the provider needs to pause for only a couple of seconds to verify a shockable rhythm and shock if necessary.

Beyond CPR, ZOLL also meets the Guidelines recommendations for post-resuscitation case review with our comprehensive RescueNet Code Review software, as well as those for biphasic defibrillation energy levels, continuous waveform capnography and STEMI management.

With its comprehensive family of integrated
devices and software, ZOLL is uniquely positioned to support every link in the now-expanded Chain of Survival. Unmatched Guidelines compliance: only from ZOLL.

*This product functionality is not available for distribution in the United States or Canada as it has not been reviewed and cleared by the FDA and/or Health Canada.

“This article originally appeared in the January 2011 JEMS supplement “Evolution in Resuscitation” as “Gearing Up for the New Standards: Companies provide insight on how they’re working to assist customers in meeting the 2010 AHA CPR Guidelines”.

 

 




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