Lindee Abe, APRN
By now, most providers have become used to taking BLS, ACLS, PALS every 2 years. It often becomes just another task on the to-do list, but no one can argue that it’s not important to have mastery in these skills when working in the emergency department, clinic, hospital, or other setting. It is through this repetition that we develop the skills these courses provide and they become engrained into our memory. Regularly refreshing our skills allows us to give better care. Similar to muscle memory, our reactions to critical situations become second nature. This articles reviews the major updates to the AHA guidelines.
When we need to use the knowledge from these courses, we are often in a high stress environment and don’t have the luxury of time to look up information. These courses are most often provided through the American Heart Association. The Red Cross also offers a BLS course. Generally, most hospitals will accept the American Heart Association programs but not all accept the Red Cross certification. Check with your employer to see which program you need.
Over the past few years, there have been some welcomed changes in the format of the classes for most healthcare providers. Ten years ago, these classes were in person for both initial certification and renewal. These courses had limited seating to preserve low student/instructor ratios. These requirements varied by the accrediting body. The advantage to this was working with hospital staff from different departments and learning from everyone’s experience. This also gave an opportunity to those that didn’t utilize these skills routinely to practice them.
For those that routinely utilized these skills, like in the emergency department, these classes could drag on and feel redundant. Most hospital systems in the area I work have now have transitioned to the hybrid model, with a portion being online and a portion being in person. The online portion reviews the material and has built in knowledge checks with a test. This allows the provider to take it at their leisure and leave and come back if needed. This provides a huge advantage to busy providers are are trying to complete training with busy practice schedules.
Skill Station learning
The second portion is the “hands on” using the skill station. At the hospital system I currently work at, they have a room set up with computerized mannequins to do the hands on portion at our leisure. This works perfect for those that only have the time to do the second portion on the weekends or late at night. Every few years we see an update to the recommendations for BLS, ACLS, and PALS. These updates are the result of ongoing research and recommendations to facilitate the best outcomes for patients. It is important that in the 2 years in between renewals for BLS, ACLS, and PALS courses, we keep up to date with the changing recommendations so we can give patients the best care possible.
The 2020 Changes
There are several notable changes to the AHA recommendations that began in 2020. The survival chain previously had 5 links, but there was a sixth link, recovery, now added to the protocol. This is important to ensure that there is a continuity of care for these critical patients. The AHA added several new algorithms to their program. These include cardiac arrest in pregnancy, two related to opioid overdose, and post-cardiac arrest care.
I am pleased to see that the new guidelines also include protocols for opioid overdose. Narcan is now recommended for all patients who are known to be taking opioids. It is important for not only the patient, but those that may have to care for that patient to feel comfortable administering the medication if needed.
Post-Cardiac Arrest Care
Post-cardiac arrest care was not previously a major topic in the AHA guidelines. Adding new guidelines is a welcomed change and ensures continued care after return of spontaneous circulation (ROSC). ROSC is just the beginning and if we don’t start the proper protocol immediately after obtaining ROSC, we will likely lose ROSC quickly. The new emphasis includes ongoing monitoring of oxygenation, blood pressure and vital signs. Percutaneous intervention (PCI) should be a priority for patients who survive cardiac arrest. The new guidelines recommend considering PCI if myocardial infarction is suspected. There is also discussion of the use of therapeutic hypothermia to preserve function, if appropriate.
Early Epinephrine, Early Intervention
Epinephrine administration is now a critical component of early management. Early intervention by bystanders is essential and increasing the number of people that have completed BLS is a great start. Continuing to emphasize early intervention in the BLS course is also helpful. This goes along with the concept that having review classes every 2 years is especially beneficial. They highlight any changes to the protocols and review the skills so they become second nature. The statistic provided by the AHA is that only 40% of adults have CPR initialed by lay persons.
The initial few minutes during a cardiac arrest are so crucial to maintaining oxygen to vital organs that this is an area we can all work together to improve. There are also only 12% of adults that receive defibrillation outside of the hospital. This is an area of continued emphasis in BLS, as it can make such a difference in outcomes.
IV route preferred over IO
Medications should be given intravenously whenever possible. Previous recommendations stressed that IO can be initiated early if unable to obtain IV access. The new guidelines place more emphasis on obtaining IV access. I’m not sure if this necessarily changes most provider’s practice as much as some of the other recommendations. There is a fine line between obtaining IV access and spending too much time delaying the administration of epinephrine due to delays in obtaining access.
The new protocols for pregnancy associated cardiac arrest emphasize the increased oxygen demands during pregnancy. Airway management should be prioritized for oxygenating pregnant patients. The AHA also clarifies that fetal monitoring should not be attempted during active resuscitation because of the interference with the resuscitation.
PALS Respiratory Rate
Several changes were made to the PALS guidelines. The most notable being the ventilation rate was change to 1 breath every 2-3 seconds from 1 breath every 6 seconds. There is also a recommendation to choose cuffed over uncuffed ETT tubes for intubation. Also, cricoid pressure no longer has sufficient evidence to justify its application in pediatric patients.
There have also been several changes in the treatment of septic shock, to include administration of fluid bolus of either 10mL/kg to 20mL/kg and the use of steroids and/or the use of either epinephrine or norepinephrine for shock unresponsive to fluid bolus. The AHA has made several other changes in their latest publication.
The new AHA guidelines bring a lot of welcomed changes. One last change is the emphasis on post cardiac arrest debriefing. This is an important aspect of the treatment of cardiac arrest to keep providers mentally fit in order to continue to treat patients effectively. We must take care of ourselves in order to take care of others.
2020. Highlights of the 2020 American Heart Association’s Guidelines. [ebook] Dallas. Available at: [Accessed 28 December 2021].
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