In Part 1 we introduced the 2019 American Heart Association (AHA) first aid, cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) guideline updates and suggested a few critical topics to be anticipated by leaders in the field of health and safety. In this article we offer details on those key updates covering first aid interventions for presyncope as well as dispatcher-assisted cardiopulmonary resuscitation (DA-CPR).
First Aid: Presyncope
For the first time in 2019, first aid¹ interventions for presyncope (a blanket term for the signs² and symptoms³ preceding loss of consciousness) were included in the AHA and American Red Cross (ARC) first aid guidelines. The goal of presyncope intervention is to prevent escalation to syncope (loss of consciousness), which has resulted in physical injury (e.g., fracture, concussion) in 30% of people who follow up in an emergency department post-syncope episode.
While the origins of presyncope vary from case to case and are not always apparent, the new guidelines specifically address presyncope resulting from decreased blood return to the heart (vasovagal or orthostatic origin). AHA/ARC suggest performing simple physical counterpressure maneuvers (PCMs) to encourage an increase in blood pressure. PCMs can be performed by anyone, including the victim experiencing presyncope, if they can identify the signs and symptoms in time.
2019 AHA Recommendations for Presyncope [ahajournals.org]
If a person experiences signs or symptoms of presyncope of vasovagal or orthostatic origin, the priority for that person is to maintain or assume a safe position, such as sitting or lying down. Once the person is in a safe position, it can be beneficial for that person to use PCMs to avoid syncope.
If a first aid provider recognizes presyncope of suspected vasovagal or orthostatic origin in another individual, it may be reasonable for the first aid provider to encourage that person to perform PCMs until symptoms resolve or syncope occurs. If no improvement occurs within 1 to 2 minutes, or if symptoms worsen or reoccur, providers should initiate a call for additional help.
If there are no extenuating circumstances, lower-body PCMs are preferable to upper-body and abdominal PCMs.
The use of PCMs is not suggested when symptoms of a heart attack or stroke accompany presyncope.
Descriptions of Recommended Physical Counterpressure Maneuvers (PCMs)MethodDescriptionLower-body PCMs*Leg crossing with muscle tensingLeg crossing with tensing of the leg, abdominal, and buttock muscles while lying down or, if necessary, while standing.SquattingLowering the body into a squatting position. Adjunctive lower-body and abdomen muscle tensing can be done during the squat and then on standing once symptoms have resolved.Upper-body PCMsArm tensingGripping opposing hands with fingers and pulling with arms in opposing directions with maximum force.Isometric handgripClenching fist at maximum contraction with or without an item in the hand.Neck flexionTouching the chin to chest and tightening the neck muscles.*PREFERRED TYPE OF PCM
Dispatcher-Assisted Cardiopulmonary Resuscitation (DA-CPR)
Updates to AHA’s guidelines for CPR/ECC include recommendations for emergency dispatch centers to instruct and guide callers when cardiac arrest is suspected. Goals of DA-CPR include increasing the likeliness of bystander CPR, identifying cardiac arrest and starting CPR sooner, increasing the quality of CPR provided by bystanders as well as improving overall outcomes for out-of-hospital cardiac arrest (OHCA) victims.
Recommendations for DA-CPR take into consideration the omnipresent mobile phone, which allows lay rescuers to activate the emergency response system (9-1-1) without leaving the victim. Lay rescuers, of all training levels, are encouraged to stay on the line with the dispatcher until emergency medical services (EMS) arrive.
2019 AHA Recommendations for DA-CPR in Adult Cases [ahajournals.org]
AHA recommends that emergency dispatch centers offer CPR instructions and empower dispatchers to provide such instructions for adult patients in cardiac arrest.
Dispatchers should instruct callers to initiate CPR for adults with suspected OHCA.
A regionalized approach to post–cardiac arrest care that includes transport of resuscitated patients directly to specialized cardiac arrest centers (CACs) is reasonable when comprehensive post–cardiac arrest care is not available at local facilities.
2019 AHA Recommendations for DA-CPR in Child & Infant Cases [ahajournals.org]
There is no previous recommendation on this topic.
We recommend that emergency medical dispatch centers offer DA-CPR instructions for presumed pediatric cardiac arrest.
We recommend that emergency dispatchers provide CPR instructions for pediatric cardiac arrest when no bystander CPR is in progress.
DA-CPR supports AHA’s growing emphasis on immediate recognition of cardiac arrest, early initiation of chest compressions and rapid defibrillation with an automated external defibrillator (AED). Use of DA-CPR does not change AHA’s accepted steps and techniques for adult, child or infant Basic Life Support (BLS), the foundation for saving lives. Regardless of exclusion from 2019 revisions, review of the BLS sequence is highly recommended and is covered in the final post of this 3-part series.
¹ The initial care provided for an acute illness or injury. The goals of first aid include preserving life, alleviating suffering, preventing further illness or injury, and promoting recovery. First aid can be initiated by anyone in any situation and includes self-care. General characteristics of the provision of first aid, at any level of training, include recognizing, assessing, and prioritizing the need for first aid; providing care using appropriate competencies; and recognizing limitations and seeking additional care when needed, such as activating emergency medical services or other medical assistance.
² Pallor/paleness, sweating, vomiting, shivering, sighing, diminished postural tone, confusion
³ Faintness, dizziness, nausea, feeling warm/hot or cold, abdominal pain, visual disturbance