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:

1. An emphasis on effective chest compressions.
2. A single compression-to-ventilation ratio (30:2) for single rescuers.
3. A recommendation that each rescue breath should be one second long and produce a visible chest rise.
4. A recommendation that a single defibrillating shock, followed by immediate CPR, be used in cases of VF cardiac arrest.
5. 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.