2015 SCIENCE UPDATES;

BLS, ACLS, & PALS

ALI HAEDAR, MD

• Clinical Lecturer & Emergency Physician,

Universitas Brawijaya

• American Heart Association's Instructor

• Professional Associate of
American Heart Association
& American Stroke Association
ADULT BASIC LIFE SUPPORT
AND CPR QUALITY
ADULT CHAINS OF SURVIVAL
CRITICAL CONCEPTS OF HIGH-QUALITY CPR
GUIDELINES RECOMMENDATIONS AND
CHANGES: BLS

Content in this section will include updated

information and scientific rationale on the following:
• Immediate recognition and activation
of emergency response system
• Emphasis on chest compressions
• Shock first vs CPR first
• Chest compression rate
• Chest compression depth
• Chest recoil
• Minimizing interruptions in
chest compressions
• Ventilation during CPR with
an advanced airway—all ages
ADULT CHAINS OF SURVIVAL
IMMEDIATE RECOGNITION AND ACTIVATION
OF EMERGENCY RESPONSE SYSTEM

2010: A very methodical process

was emphasized
• Check for responsiveness
• Check for no breathing or
no normal breathing
• Call for help
• Check for pulse

2015: A more simultaneous

and realistic approach
• Call for nearby help
• Assess breathing and pulse
simultaneously
• Activate emergency response
system or call for backup
CHECKING BREATHING AND PULSE

2015
• Simultaneous breathing and pulse check
in less than 10 seconds
EMPHASIS ON CHEST COMPRESSIONS

• The foundation of quality CPR is good

chest compressions

• Healthcare providers should provide chest

compressions and ventilations

• But it’s important to tailor the sequence

of compressions to the most likely cause of arrest,
and adjust to circumstances
SHOCK FIRST VS CPR FIRST

2010
• 1½ to 3 minutes of CPR may be considered before
attempted defibrillation

2015
• For witnessed adult cardiac arrest when an AED is
immediately available, use as soon as it is ready
• For unwitnessed adult cardiac arrest, or when an AED
is not immediately available, immediately start CPR
while the AED is being retrieved and while it’s being
applied to the victim. Then use as soon as it is ready
• CPR should be provided while the AED pads are being
applied and until the AED is ready to analyze the rhythm
CHEST COMPRESSION RATE

2010
• Deliver chest
compressions at
a rate of at least
100/min

2015
• Deliver chest
compressions at
a rate of 100 to 120/min
CHEST COMPRESSION DEPTH

2010
• The adult sternum
should be depressed at
least 2 inches (5 cm)

2015
• During manual CPR,
chest compressions
should be at least 2
inches (5 cm) but no more
than 2.4 inches (6 cm)
EMPHASIS ON CHEST COMPRESSION DEPTH

• Difficult to judge compression depth

without use of feedback devices

• Chest compression depth is more often too

shallow than too deep

• A compression depth of approximately

2 inches (5 cm) is associated with greater
likelihood of favorable outcomes compared with
shallower compressions. Research suggests
potential injury when compressions are too deep
(greater than 2.4 inches [6 cm])
CHEST RECOIL

2010
• Allow complete recoil
of the chest after each
compression, to allow
the heart to fill
completely before the
next compression

2015
• Avoid leaning on the
chest between
compressions to allow
full chest wall recoil
MINIMIZING INTERRUPTIONS IN
CHEST COMPRESSIONS

• All rescuers should minimize the

frequency and duration of interruptions
in chest compressions

• New for 2015: For adults in cardiac arrest who

receive CPR without an advanced airway, performing
CPR with the goal of a chest compression fraction of
at least 60% is recommended, and a goal of
80% is often achievable with good teamwork
VENTILATION DURING CPR WITH AN
ADVANCED AIRWAY

2010
• Give 1 breath every 6 to 8
seconds with continuous
chest compressions

2015
• Give 1 breath every 6
seconds with continuous
chest compressions
PEDIATRIC BASIC LIFE SUPPORT
AND CPR QUALITY
ADULT CHAINS OF SURVIVAL
ADULT CHAINS OF SURVIVAL
GUIDELINES RECOMMENDATIONS AND
CHANGES: PEDIATRIC BLS

Content in this section will include updated

information and scientific rationale on the following:
• Immediate recognition and
activation of emergency
response system
• C-A-B sequence
• Chest compression rate
• Chest compression depth
• Reaffirmation that compressions
and ventilations are needed
for pediatric BLS
IMMEDIATE RECOGNITION AND ACTIVATION
OF EMERGENCY RESPONSE SYSTEM

• New algorithms for single- and multiple-rescuer

pediatric HCP CPR in the era of cell phones
• In a continuous effort to minimize delay, the
encouragement of simultaneous assessment
of breathing and pulse
• Simultaneous assessment of breathing and
pulse that mirrors adult recommendations
C-A-B SEQUENCE

The CPR sequence is unchanged from 2010:

• 1 rescuer: Begin with 30 compressions

followed by 2 breaths

• 2 rescuers: Begin with 15 compressions

followed by 2 breaths
CHEST COMPRESSION RATE

2010
• Push at a rate of at least
100/min

2015
• Rate for infants
and children:
100 to 120/min
CHEST COMPRESSION DEPTH

• Provide chest compressions at least one third AP

diameter of chest in pediatric patients

• Infants: Approximately 1.5 inches (4 cm)

• Children: 2 inches (5 cm)
• At puberty: Follow adult recommendations
• Adults: Compressions should be at least
2 inches (5 cm) but no more than
2.4 inches (6 cm)
REAFFIRMATION THAT COMPRESSIONS AND
VENTILATIONS ARE NEEDED FOR PEDIATRIC BLS

2015
• The asphyxial nature of
most pediatric cardiac
arrests necessitates
ventilation as part of
effective CPR

• Conventional CPR of
rescue breaths and
chest compressions
best for pediatric patients
ACLS 2015 SCIENCE UPDATES
ADULT CHAINS OF SURVIVAL
ELEMENTS OF EFFECTIVE
HIGH-PERFORMANCE TEAM DYNAMICS
ADULT CHAINS OF SURVIVAL
ADULT CHAINS OF SURVIVAL
ADVANCED AIRWAY VENTILATION RATE

• Deliver 1 breath every 6

seconds (10 breaths per
minute) while continuous
chest compressions are
being performed

• Single rate for adults

should be easier to learn,
remember, and perform
TARGETED TEMPERATURE MANAGEMENT (TTM)

• Targeted temperature
between 32°C and 36°C
selected and achieved,
by administering 1-2 L of
normal saline, then
maintained constantly
for at least 24 hours

• Improvement in
neurologic outcome
for those in whom
hypothermia was induced
OUT-OF-HOSPITAL COOLING

• Routine prehospital cooling of

patients with rapid infusion of
cold IV fluids after ROSC is no
longer recommended

• Studies demonstrated no benefit

to prehospital cooling and also
identified potential complications
when using cold IV fluids for
prehospital cooling
VASOPRESSORS FOR RESUSCITATION:
VASOPRESSIN

• Vasopressin in combination with

epinephrine offers no advantage
as a substitute for standard-dose
epinephrine in cardiac arrest

• Efficacy of the two drugs is

similar, and there is no
demonstrable benefit from
administering both epinephrine
and vasopressin as compared
with epinephrine alone

• For simplicity, vasopressin has

been removed from the algorithm
VASOPRESSORS FOR RESUSCITATION:
EPINEPHRINE

• Administer epinephrine as soon

as feasible after the onset of
cardiac arrest due to an initial
nonshockable rhythm

• Association between early

administration of epinephrine
and increased ROSC, survival
to hospital discharge, and
neurologically intact survival
ELEMENTS OF EFFECTIVE
HIGH-PERFORMANCE TEAM DYNAMICS
ACLS 2015 SCIENCE UPDATES:
ACUTE CORONARY SYNDROME
and STROKE
REEMPHASIS OF HIGH QUALITY CPR
CHEST COMPRESSION RATE AND DEPTH
RECOMMENDATIONS FOR FLUID
RESUSCITATION
PALS 2015 SCIENCE UPDATES:
PEDIATRIC ADVANCED LIFE
SUPPORT AND CPR QUALITY
REEMPHASIS OF HIGH QUALITY CPR
CHEST COMPRESSION RATE AND DEPTH
REEMPHASIS OF HIGH QUALITY CPR

• Push hard
• Push fast
• Minimize interruptions
• Avoid excessive ventilation
– Slight modification of advanced airway ventilation rate: 10
breaths/minute (one every six seconds)
• Allow full chest recoil
CHEST COMPRESSION RATE AND DEPTH

• Use the recommended

adult chest compression
rate of 100 to 120/min for
infants and children
• Depth: Push Hard
• At least 1/3 AP chest diameter
– ~4cm (1.5 inches) for
infants
– ~5cm (2 inches) for children
– 5-6cm (2-2.4 inches) for
“average” sized adolescent
RECOMMENDATIONS FOR FLUID
RESUSCITATION

• Initial fluid bolus of 20 mL/kg

• Emphasizes the administration
of IV fluid for children with
septic shock
• Emphasizes individualized
treatment plans for each
patient, based on frequent
clinical assessment before,
during, and after fluid therapy
ATROPINE FOR ENDOTRACHEAL
INTUBATION

• There is no evidence to support

the routine use of atropine as
a premedication to prevent
bradycardia in emergency
pediatric intubations
• It may be considered in
situations where there is an
increased risk of bradycardia
ANTIARRHYTHMIC MEDICATIONS

• Amiodarone or lidocaine is
equally acceptable for the
treatment of shock-refractory
VF or pVT in children
• Compared with amiodarone,
lidocaine was associated with
higher rates of ROSC and
24-hour survival
• Neither lidocaine nor
amiodarone administration
was associated with improved
survival to hospital discharge
TARGETED TEMPERATURE MANAGEMENT

• For children who are comatose

in the first several days after
cardiac arrest (in-hospital or
out-of-hospital), temperature
should be monitored
continuously and fever should
be treated aggressively
• For comatose children
resuscitated from OHCA,
maintain either 5 days of
normothermia (36°C to 37.5°C)
or 2 days of initial continuous
hypothermia (32°C to 34°C)
followed by 3 days
of normothermia
EXTRACORPOREAL CPR FOR IN-HOSPITAL
PEDIATRIC CARDIAC ARREST

• ECPR may be considered for pediatric patients with

cardiac diagnoses who have in-hospital cardiac
arrest (IHCA) in settings with existing ECMO
protocols, expertise, and equipment

–For children with underlying cardiac disease,

long-term survival has been reported even after
more than 50 minutes of conventional CPR

–When ECPR is used during cardiac arrest, the

outcome for children with underlying cardiac
disease is better than for those with non-cardiac
disease
POST–CARDIAC ARREST FLUIDS AND
INOTROPES

• After ROSC, use parenteral fluids and/or inotropes

or vasoactive drugs be used to maintain a systolic
blood pressure greater than fifth percentile for age

• When appropriate resources are available,

continuous arterial pressure monitoring is
recommended to identify and treat hypotension
POST–CARDIAC ARREST OXYGENATION

• Target normoxemia after ROSC. Because an

arterial oxyhemoglobin saturation of 100% may
correspond to a PaO2 anywhere between 80-500
mm Hg, it may be reasonable - when the necessary
equipment is available - for rescuers to wean
oxygen to target an oxyhemoglobin saturation of
less than 100%, but 94% or greater.

• The goal is to achieve normoxemia while ensuring

that hypoxemia is strictly avoided
PALS 2015 SCIENCE UPDATES:
NEONATAL RESUSCITATION
ACCESSING RESOURCES

For further reading of AHA’s guidelines,

please refer to:

• 2015 Guidelines Highlights at

https://eccguidelines.heart.org/
• Educational Communication at
www.heart.org
• Seri Panduan klinis
BLS, ACLS, dan PALS
Thank You

Contact:
Email: haedaryahya@yahoo.com