American Heart Association changes CPR guidelines

'If we can just get people to start the compressions, then we can look at saving a lot more lives' says board member of the AHA

By Erin Allday
The San Francisco Chronicle

SAN FRANCISCO — Two of the three pillars of CPR — opening a distressed person's airway and providing mouth-to-mouth breathing — turn out to be not so essential when it comes to saving the life of someone in cardiac arrest.

Cardiopulmonary resuscitation should begin with forceful chest compressions to keep the blood circulating through the body, according to new guidelines released today by the American Heart Association. And people who haven't been trained in CPR need not bother with providing air-passage clearance and mouth-to-mouth breathing at all, the group said.

For the first time in decades, the heart association is shaking up its ABC system: airway, breathing and circulation. Until now, it involved opening the victim's airway first, starting mouth-to-mouth breathing and doing chest compressions last.

Several large studies in the past five years, however, have found that skipping the first two steps and going straight to chest compressions yields better survival rates for people who suffer cardiac arrest. Meanwhile, by discouraging the average citizen from giving mouth-to-mouth emergency treatment, public health experts hope that more people will be willing to provide CPR to strangers.

"This is a major change. If we can just get people to start the compressions, then we can look at saving a lot more lives," said Dr. Gordon Fung, director of cardiac services at UCSF Medical Center and a board member of the San Francisco chapter of the American Heart Association.

The heart association has taught CPR to the public using the ABC system since the 1960s. Sudden cardiac arrest is a common cause of death in the United States, and only about 6 percent of victims whose hearts stop outside of a hospital survive. But CPR may as much as double the chances of survival, studies have shown.

Reluctant bystanders
Two years ago, the heart association began encouraging untrained bystanders to forego mouth-to-mouth and give chest compressions when someone collapses. Multiple studies had shown that any CPR was better than none at all, but lay people were reluctant to step in and help — perhaps in large part because they didn't want to provide mouth-to-mouth breathing.

"But the message is that you don't need to do mouth-to-mouth," said Dr. Ed Kersh, chief of cardiology at California Pacific Medical Center's St. Luke's campus. "The key is getting the circulation going again."

The only time mouth-to-mouth breathing may be necessary is in obvious cases where a person is in respiratory distress — when someone has clearly stopped breathing from drowning, for example, or from a drug overdose.

But because the vast majority of cases where a person collapses and stops breathing are due to cardiac arrest, public health experts say starting chest compressions should almost always be the priority.

In the most recent CPR study, which looked at 4,400 cardiac arrest patients and was published last week in the Journal of the American Heart Association, 13 percent of victims who got CPR using chest compressions alone survived and were eventually discharged from a hospital.

But only 7.8 percent of those who got traditional CPR with rescue breathing were discharged, which wasn't much better than the 5.2 percent of people who received no CPR at all and eventually left the hospital.

The thinking is that rescuers who use traditional CPR waste valuable time — as much as half a minute — adjusting the head to set up an airway and then providing a breath or two before starting chest compressions.

Get the blood moving
The body probably already has enough oxygen in it when a person collapses, meaning breathing usually isn't the immediate concern. What's important is getting the blood moving again and supplying vital organs with oxygen until help arrives in the form of a defibrillator, which can be used to get the heart beating on its own again.

"You're looking to push oxygenated blood to the brain and to the heart," said Dr. George Bulloch, chief of the Kaiser Permanente Redwood City emergency department. "There is enough oxygen intrinsically built in that you can concentrate on just circulating it. You're just trying to buy time until EMS can get there and supply a shock."

The new heart association guidelines also recommend more aggressive chest compressions, including faster and deeper pushes on the sternum. Rescuers should do chest compressions at a rate of 100 per minute, and push a good 2 inches down.

If the rescuer is trained in CPR, he or she may still give mouth-to-mouth assistance, at a rate of two breaths after 30 chest compressions.

One of the other advantages of recommending chest compressions only for most bystanders is that it's easy for a 911 operator to talk someone through the simpler form of CPR.

"If you call 911 and they say bend down and push, that's a quick trick," Bulloch said. "It will be eminently easier to teach."

The new CPR Here are the American Heart Association's new guidelines for cardiopulmonary resuscitation: Before starting, shake the victim's shoulders and shout to see if he responds. If the victim is not breathing, yell for someone to call 911. If you're alone, call 911. Begin chest compressions. Push hard and fast on the center of the chest at a rate of at least 100 compressions a minute which happens to be the beat of the 1977 Bee Gees disco hit "Stayin' Alive". Push down on the chest at least 2 inches with each compression. Make sure you fully release the chest before beginning the next compression. If you have not been trained in CPR, continue chest compressions until help arrives. If you have been trained, after 30 chest compressions open an airway and begin mouth-to-mouth breathing. Give two breaths, then resume chest compressions. Continue sets of 30 chest compressions and two breaths until help arrives.

"This is a major change. If we can just get people to start the compressions, then we can look at saving a lot more lives."

2010 CPR Guidelines

How the American Heart Association's CPR Guidelines Have Changed for 2010

By Rod Brouhard, About.com Guide

Updated October 18, 2010

After a review of the available research published over a 5 year period, the American Heart Association released its 2010 CPR Guidelines. As expected, the focus for CPR is on good quality chest compressions. Here are the differences between the 2005 and the 2010 CPR Guidelines:

• A-B-C is for babies; now it's C-A-B!

  It used to be follow your ABC's: airway, breathing and chest compressions. Now, Compressions come first, only then do you focus on Airway and Breathing. The only exception to the rule will be newborn babies, but everyone else -- whether it's infant CPR, child CPR or adult CPR -- will get chest compressions before you worry about the airway.

  Why did CPR change from A-B-C to C-A-B?

• No more looking, listening and feeling.

  The key to saving a cardiac arrest victim is action, not assessment. Call 911 the moment you realize the victim won't wake up and doesn't seem to be breathing right.

  Trust your gut. If you have to hold your cheek over the victim's mouth and carefully try to detect a puff of air, it's a pretty good bet she's not breathing very well, if at all.

  I have a secret to share: paramedics have been doing it this way for years. Rarely have I seen an EMT or a paramedic put her ear to a victim's nose and listen for air movement. We just get to work.

• Push a little harder. How deep you should push on the chest has changed for adult CPR. It was 1 1/2 to 2 inches, but now the Heart Association wants you to push at least 2 inches deep on the chest.
• Push a little faster. AHA changed the wording here, too. Instead of pushing on the chest at about 100 compressions per minute, AHA wants you to push at least 100 compressions per minute. At that rate, 30 compressions should take you 18 seconds.

Besides the changes under the 2010 CPR Guidelines, AHA continues to emphasize some important points:

• Hands Only CPR. This is technically a change from the 2005 Guidelines, but AHA endorsed this form of CPR in 2008. The Heart Association still wants untrained lay rescuers to do Hands Only CPR on adult victims who collapse in front of them. My biggest problem with this campaign is what's left unsaid. What does AHA want untrained lay rescuers to do with all the other victims? In other words, what do you do with the victims that aren't adults or that didn't collapse right in front of you? AHA doesn't provide an answer, but I have a suggestion: Do Hands Only CPR, because doing something is always better than doing nothing.
• Recognize sudden cardiac arrest. CPR is the only treatment for sudden cardiac arrest and AHA wants you to notice when it happens.
• Don't stop pushing. Every interruption in chest compressions interrupts blood flow to the brain, which leads to brain death if the blood flow stops too long. It takes several chest compressions to get blood moving again. AHA wants you to keep pushing as long as you can. Push until the AED is in place and ready to analyze the heart. When it is time to do mouth to mouth, do it quick and get right back on the chest.

Source:

Field JM, Hazinski MF, Sayre MR, Chameides L, Schexnayder SM, Hemphill R, Samson RA, Kattwinkel J, Berg RA, Bhanji F, Cave DM, Jauch EC, Kudenchuk PJ, Neumar RW, Peberdy MA, Perlman JM, Sinz E, Travers AH, Berg MD, Billi JE, Eigel B, Hickey RW, Kleinman ME, Link MS, Morrison LJ, O’Connor RE, Shuster M, Callaway CW, Cucchiara B, Ferguson JD, Rea TD, Vanden Hoek TL. "Part 1: executive summary: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care." Circulation. 2010;122(suppl 3):S640–S656.

Urinary Tract Infections

The urinary tract is the body's filtering system for removal of liquid wastes. Because we have a shorter urinary tract, women are especially susceptible to bacteria that may invade the urinary tract and multiply -- resulting in infection known as a urinary tract infection, or UTI.

Although most UTIs are not serious, they can be a painful nuisance. Approximately 50 percent of all women will have at least one UTI in her lifetime with many women having several infections throughout their lifetime. Fortunately, these infections are easily treated with antibiotics. Some women are more prone to recurrent UTIs than others and for them it can be a frustrating battle.

What Causes Urinary Tract Infections?

The most common cause of UTIs are bacteria from the bowel that live on the skin near the rectum or in the vagina, which can spread and enter the urinary tract through the urethra. Once these bacteria enter the urethra, they travel upward, causing infection in the bladder and sometimes other parts of the urinary tract.

Sexual intercourse is a common cause of urinary tract infections because the female anatomy can make women more prone to urinary tract infections. During sexual activity, bacteria in the vaginal area are sometimes massaged into the urethra.

Women who change sexual partners or begin having sexual intercourse more frequently may experience bladder or urinary tract infections more often than women who are celibate or in monogamous relationships. Although it is rare, some women get a urinary tract infection every time they have sex.

Another cause of bladder infections or UTI is waiting too long to urinate. The bladder is a muscle that stretches to hold urine and contracts when the urine is released. Waiting too long past the time you first feel the need to urinate can cause the bladder to stretch beyond its capacity. Over time, this can weaken the bladder muscle. When the bladder is weakened, it may not empty completely and some urine is left in the bladder. This may increase the risk of urinary tract infections or bladder infections.

Other factors that also may increase a woman's risk of developing UTI include pregnancy, having urinary tract infections or bladder infections as a child, menopause, or diabetes.

What Are the Symptoms of Urinary Tract Infections?

Symptoms of UTI or bladder infection are not easy to miss and include a strong urge to urinate that cannot be delayed, which is followed by a sharp pain or burning sensation in the urethra when the urine is released. Most often very little urine is released and the urine that is released may be tinged with blood. The urge to urinate recurs quickly and soreness may occur in the lower abdomen, back, or sides.

This cycle may repeat itself frequently during the day or night--most people urinate about six times a day, when the need to urinate occurs more often a bladder infection should be suspected.

When bacteria enter the ureters and spread to the kidneys, symptoms such as back pain, chills, fever, nausea, and vomiting may occur, as well as the previous symptoms of lower urinary tract infection.

Proper diagnosis is vital since these symptoms also can be caused by other problems such as infections of the vagina or vulva. Only your physician can make the distinction and make a correct diagnosis.

How Is a Diagnosis of UTI Made?

The number of bacteria and white blood cells in a urine sample is the basis for diagnosing urinary tract infections. Urine is examined under a microscope and cultured in a substance that promotes the growth of bacteria. A pelvic exam also may be necessary.

Note: If you have recurrent UTIs and bladder infections, you may be interested in purchasing an at-home test for UTI, which is available over-the-counter (OTC) without a prescription. The test consists of a dipstick that changes color when you have a urinary tract infection. The test detects the presence of nitrite. Bacteria changes normal nitrates in the urine to nitrite. The test, which works best on first morning urine, is about 90% reliable.

What Is the Treatment for Urinary Tract Infections?

Antibiotics (medications that kill bacteria) are the usual treatment for bladder infections and other urinary tract infections. Seven to ten 10 of antibiotics is usually required, although some infections may require only a single dose of antibiotics.

It's important that all antibiotics are taken as prescribed. Antibiotics should not be discontinued before the full course of antibiotic treatment is complete. Symptoms may disappear soon after beginning antibiotic treatment. However, if antibiotics are stopped early, the infection may still be present and recur.

An additional urine test may be ordered about a week after completing treatment to be sure the infection is cured.

Tips for Preventing Urinary Tract Infections

• The most important tip to prevent urinary tract infections, bladder infections, and kidney infections is to practice good personal hygiene. Always wipe from front to back after a bowel movement or urination, and wash the skin around and between the rectum and vagina daily. Washing before and after sexual intercourse also may decrease a woman's risk of UTI.
• Drinking plenty of fluids (water) each day will help flush bacterium out of the urinary system.
• Emptying the bladder as soon as the urge to urinate occurs also may help decrease the risk of bladder infection or UTI.
• Urinating before and after sex can flush out any bacteria that may enter the urethra during sexual intercourse.
• Vitamin C makes the urine acidic and helps to reduce the number of potentially harmful bacteria in the urinary tract system.
• Wear only panties with a cotton crotch, which allows moisture to escape. Other materials can trap moisture and create a potential breeding ground for bacteria. Avoid thongs.
• Cranberry juice is often said to reduce frequency of bladder infections, though it should not be considered an actual treatment. Cranberry supplements are available over-the-counter and many women find they work when an UTI has occurred; however, a physician's diagnosis is still necessary even if cranberry juice or related herbals reduce pain or symptoms.
• If you experience frequent urinary tract infections changing sexual positions that cause less friction on the urethra may help. Some physicians prescribe an antibiotic to be taken immediately following sex for women who tend to have frequent UTIs.

Things to Remember...

Although urinary tract infections are common and distinctly painful, they usually are easy to treat once properly diagnosed and only last a few days. When treated promptly and properly, UTIs are rarely serious.

Source:

Urinary Tract Infection. Medline Plus. http://www.nlm.nih.gov/medlineplus/ency/article/000521.htm. Accessed 10/7/2010.