2015 Interim Resources for HeartCode® PALS Original Release: November 25, 2015
Starting in 2016, new versions of American Heart Association online courses will be released to reflect the changes published in the 2015 AHA Guidelines Update for CPR and ECC. All current AHA courses remain valid and should continue to be used for training until the new versions are released. The release of new Guidelines does not mean that the use of earlier Guidelines is unsafe or ineffective. To ensure that students in current courses are aware of the changes in science, the following interim resources are available free of charge for HeartCode PALS students: •
Highlights of the 2015 American Heart Association Guidelines Update for CPR and ECC (available at 2015ECCguidelines.heart.org): In-depth summary by topic of the changes to science and treatment recommendations published in the 2015 AHA Guidelines Update for CPR and ECC
•
PALS Provider Manual Comparison Chart (attached): Chart showing how science changes in the 2015 AHA Guidelines Update for CPR and ECC differ from current PALS course content
•
Interim PALS Course 1- and 2-Rescuer Child BLS With AED Skills Testing Sheet (attached): Checklist of critical performance steps updated with 2015 science changes
•
Interim PALS Course 1- and 2-Rescuer Infant BLS Skills Testing Sheet (attached): Checklist of critical performance steps updated with 2015 science changes
2015 Interim Training Materials PALS Provider Manual Comparison Chart Chest compression rate (Part 1, BLS Competency Testing; apply update throughout course as needed)
Ventilation during CPR with an advanced airway (Part 1, BLS Competency Testing; apply update throughout course as needed)
New Push at a rate of 100 to 120 compressions per minute for infants and children.
Old Push at a rate of at least 100 compressions per minute.
It may be reasonable for the provider to deliver 1 breath every 6 seconds (10 breaths per minute) while continuous chest compressions are being performed (ie, during CPR with an advanced airway).
When an advanced airway (ie, endotracheal tube, Combitube, or laryngeal mask airway) is in place during 2-person CPR, give 1 breath every 6 to 8 seconds without attempting to synchronize breaths between compressions (this will result in delivery of 8 to 10 breaths per minute).
PALS Provider Manual Comparison Chart
Rationale A single large registry series suggested that as the compression rate increases to more than 120/min, compression depth decreases in a dose-dependent manner. For example, the proportion of compressions of inadequate depth was about 35% for a compression rate of 100 to 119/min but increased to inadequate depth in 50% of compressions when the compression rate was 120 to 139/min and to inadequate depth in 70% of compressions when the compression rate was more than 140/min. This simple single rate for children and infants—rather than a range of breaths per minute—should be easier to learn, remember, and perform.
1
New
Recommendations for fluid resuscitation (Part 7, Rate and Volume of Fluid Administration)
Old For children in shock, Children with septic shock an initial fluid bolus of 20 mL/kg is typically require at least 60 mL/kg reasonable. However, for of isotonic crystalloid solution children with febrile illness in settings during the first hour of therapy; with limited access 200 mL/kg or more may be to critical care resources (ie, mechanical ventilation and required in the first 8 hours of inotropic support), administration of therapy. bolus IV fluids should be undertaken with extreme caution, as it may be harmful. Individualized treatment and frequent clinical reassessment are emphasized.
PALS Provider Manual Comparison Chart
Rationale This recommendation continues to emphasize the administration of IV fluid for children with septic shock. Additionally, it emphasizes individualized treatment plans for each patient, based on frequent clinical assessment before, during, and after fluid therapy is given, and it presumes the availability of other critical care therapies. In certain resourcelimited settings, excessive fluid boluses given to febrile children may lead to complications where the appropriate equipment and expertise might not be present to effectively address them.
2
New Atropine for endotracheal intubation (Part 8, Atropine)
There is no evidence to support the routineuse of atropine as a premedication to prevent bradycardiain emergency pAs shown
in rows 1 through 3, changes to the assessment sequence have been made to allow for consistency with the BLS course and also include a simultaneous breathing and pulse check.A student can choose to perform a breathing and pulse check separately, each for no less than 5 seconds and no more than 10 seconds. Or these actions may be performed simultaneously, for a minimum of 5 seconds and a maximum of 10 seconds.
Old Atropine for endotracheal intubation: A minimum atropine dose of 0.1 mg IV was recommended because of reports of paradoxical bradycardia occurring in very small infants who received low doses of atropine.
Rationale Recent evidence is conflicting as to whether atropine prevents bradycardia and other arrhythmias during emergency intubation in children. However, these recent studies did use atropine doses less than 0.1 mg without an increase in the likelihood of arrhythmias.
Row 6 shows that the ompression rate has been updated to 100 to 120 compressions per minute. The student should deliver 30 compressions in no less than 15 and no more than 18 seconds. While there are clarifications in the chest compression depth recommendations, an upper limit is not evaluated pediatric intubations. It may be considered in situations where there is an increased risk of bradycardia. There is no evidence to support a minimum dose of atropine when used as a premedication for emergency intubation.
PALS Provider Manual Comparison Chart
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Antiarrhythmic medications for shock-refractory VF or pulseless VT (Part 10, Table 2: Pediatric Cardiac Arrest Medication, and Pediatric Cardiac Arrest Algorithm) Targeted temperature management (Part 11, Neurologic System, General Recommendations, “Temperature control” row)
New Amiodarone or lidocaine is equally acceptable for the treatment of shock-refractory ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT).
Old Amiodarone was recommended for shock-refractory VF or pVT. Lidocaine can be given if amiodarone is not available.
For comatose children resuscitated from out-of-hospital cardiac arrest it is reasonable for caretakers to maintain either 5 days of normothermia (36°C to 37.5°C) followed by 3 days of normothermia.
Therapeutic hypothermia (32°C to 34°C) may be considered for children who remain comatose after resuscitation from cardiac arrest. It is reasonable for adolescents resuscitated from witnessed out-of-hospital VF arrest
Rationale A recent, retrospective, multi-institution registry of inpatient pediatric cardiac arrest showed that, compared with amiodarone, lidocaine was associated with higher rates of return of spontaneous circulation and 24-hour survival. However, neither lidocaine nor amiodarone administration was associated with improved survival to hospital discharge. Initial studies of targeted temperature management (TTM) examined cooling to temperatures between 32°C and 34°C compared with no well-defined TTM and found improvement in neurologic outcome for those in whom hypothermia was induced. A recent high-quality study compared temperature management at 36°C and at 33°C and found outcomes to be similar for both. Taken together, the initial studies suggest that TTM is beneficial, so the recommendation remains to select a single target temperature and perform TTM. Given that 33°C is no better than 36°C, clinicians can select from a wider range of target temperatures. The selected temperature may be determined by clinician preference or clinical factors.
PALS Provider Manual Comparison Chart
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PALS Course―2015 Interim Tool
1- and 2-Rescuer Child BLS With AED Skills Testing Sheet Student Name:
Test Date:
1-Rescuer BLS and CPR Skills (circle one): 2-Rescuer CPR Skills Bag-Mask (circle one): AED Skills (circle one):
Skill Step
Pass
Needs Remediation
Pass Pass
Needs Remediation Needs Remediation
Critical Performance Criteria
✓ if done
correctly
1-Rescuer Child BLS Skills Evaluation During this first phase, evaluate the first rescuer’s ability to initiate BLS and deliver high-quality CPR for 5 cycles. 1
Checks responsiveness
2
Yells for help, activates the emergency response system, and sends for an AED
3
Checks breathing and pulse (breathing and pulse check can be performed simultaneously) for at least 5 seconds and no more than 10 seconds
4
GIVES HIGH-QUALITY CPR (30:2): • Correct compression HAND PLACEMENT • ADEQUATE RATE: 100 to 120/min (ie, delivers each set of 30 chest compressions in no less than 15 seconds and no more than 18 seconds), using 1 or 2 hands
Cycle 1:
• ADEQUATE DEPTH: Delivers compressions at least one third the depth of the chest (approximately 2 inches [5 cm]) (at least 23 out of 30)
Cycle 3:
• ALLOWS COMPLETE CHEST RECOIL (at least 23 out of 30)
Cycle 4:
• MINIMIZES INTERRUPTIONS: Gives 2 breaths with pocket mask in less than 10 seconds
Cycle 5:
Cycle 2:
Time:
Second Rescuer AED Skills Evaluation and SWITCH During this next phase, evaluate the second rescuer’s ability to use the AED and both rescuers’ abilities to switch roles. 5
DURING FIFTH SET OF COMPRESSIONS: Second rescuer arrives with AED and bag-mask device, turns on AED, and applies pads
6
First rescuer continues compressions while second rescuer turns on AED and applies pads
7
Second rescuer clears victim, allowing AED to analyze—RESCUERS SWITCH
8
If AED indicates a shockable rhythm, second rescuer clears victim again and delivers shock
First Rescuer Bag-Mask Ventilation During this next phase, evaluate the first rescuer’s ability to give breaths with a bag-mask device. 9
Both rescuers RESUME HIGH-QUALITY CPR immediately after shock delivery: • SECOND RESCUER gives 15 compressions in no less than 7 seconds and no more than 9 seconds (for 2 cycles)
Cycle 1
Cycle 2
Time:
• FIRST RESCUER successfully delivers 2 breaths with bag-mask (for 2 cycles) AFTER 2 CYCLES, STOP THE EVALUATION • If the student completes all steps successfully (a ✓ in each box to the right of Critical Performance Criteria), the student passed this scenario. • If the student does not complete all steps successfully (as indicated by a blank box to the right of any of the Critical Performance Criteria), give the form to the student for review as part of the student’s remediation. • After reviewing the form, the student will give the form to the instructor who is reevaluating the student. The student will reperform the entire scenario, and the instructor will notate the reevaluation on this same form. • If the reevaluation is to be done at a different time, the instructor should collect this sheet before the student leaves the classroom. Remediation (if needed): Instructor Signature:
Instructor Signature:
Print Instructor Name:
Print Instructor Name:
Date:
Date:
PALS Course―2015 Interim Tool
1- and 2-Rescuer Infant BLS Skills Testing Sheet Student Name:
Test Date:
1-Rescuer BLS and CPR Skills (circle one): 2-Rescuer CPR Skills Bag-Mask (circle one): 2 Thumb–Encircling Hands (circle one):
Skill Step
Pass
Needs Remediation
Pass Pass
Needs Remediation Needs Remediation
Critical Performance Criteria
✓ if done
correctly
1-Rescuer Infant BLS Skills Evaluation During this first phase, evaluate the first rescuer’s ability to initiate BLS and deliver high-quality CPR for 5 cycles. 1
Checks responsiveness
2
Yells for help, activates the emergency response system, and sends for an AED
3
Checks breathing and pulse (breathing and pulse check can be performed simultaneously) for at least 5 seconds and no more than 10 seconds
4
GIVES HIGH-QUALITY CPR: • Correct compression FINGER PLACEMENT
Cycle 1:
• ADEQUATE RATE: 100 to 120/min (ie, delivers each set of 30 chest compressions in no less than 15 seconds and no more than 18 seconds) • ADEQUATE DEPTH: Delivers compressions at least one third the depth of the chest (approximately 1½ inches [4 cm]) (at least 23 out of 30) • ALLOWS COMPLETE CHEST RECOIL (at least 23 out of 30)
Cycle 2:
• MINIMIZES INTERRUPTIONS: Gives 2 breaths with pocket mask in less than 10 seconds
Cycle 5:
Time:
Cycle 3: Cycle 4:
2-Rescuer CPR and SWITCH During this next phase, evaluate the FIRST RESCUER’S ability to give breaths with a bag-mask device and give compressions by using the 2 thumb–encircling hands technique. Also evaluate both rescuers’ abilities to switch roles. 5 DURING FIFTH SET OF COMPRESSIONS: Second rescuer arrives with bag-mask device. RESCUERS SWITCH ROLES. Cycle 1 Cycle 2 6 Both rescuers RESUME HIGH-QUALITY CPR: • SECOND RESCUER gives 15 compressions in no less than 7 seconds and no more than 9 seconds by using 2 thumb–encircling hands technique (for 2 cycles)
X
X
• FIRST RESCUER successfully delivers 2 breaths with bag-mask (for 2 cycles) AFTER 2 CYCLES, PROMPT RESCUERS TO SWITCH ROLES 7
Cycle 1
Both rescuers RESUME HIGH-QUALITY CPR: • FIRST RESCUER gives 15 compressions in no less than 7 seconds and no more than 9 seconds by using 2 thumb–encircling hands technique (for 2 cycles) • SECOND RESCUER successfully delivers 2 breaths with bag-mask (for 2 cycles)
• • • •
Cycle 2
Time:
Time:
X
X
AFTER 2 CYCLES, STOP THE EVALUATION If the student completes all steps successfully (a ✓ in each box to the right of Critical Performance Criteria), the student passed this scenario. If the student does not complete all steps successfully (as indicated by a blank box to the right of any of the Critical Performance Criteria), give the form to the student for review as part of the student’s remediation. After reviewing the form, the student will give the form to the instructor who is reevaluating the student. The student will reperform the entire scenario, and the instructor will notate the reevaluation on this same form. If the reevaluation is to be done at a different time, the instructor should collect this sheet before the student leaves the classroom. Remediation (if needed):
Instructor Signature:
Instructor Signature:
Print Instructor Name:
Print Instructor Name:
Date:
Date: 25
