American Heart Association 2010 Acls Guidelines:: What Every Clinician Needs To Know

AMERICAN HEART
ASSOCIATION 2010 ACLS

GUIDELINES:
WHAT EVERY CLINICIAN
NEEDS TO KNOW
Joseph Heidenreich, MD
Texas A&M Health Science Center
Scott & White Memorial Hospital
Scott & White Memorial Hospital
Advanced Cardiac Life Support
- 400 residents & fellows
- 100 medical students
- 900 physicians
- 2800 nurses
AHA 2010 BLS Unrres]10nSiiVe
No b:r-eathingl 01"
Guidelines no.' non11al
breBUiirngl
(only rgra1lp~lI1gl
C-A-B Activace
emergenc
y
Get;
d'e:fib'n~llator' ~
.~.
Ir.esponse
 ABC is not longer

StartlCPFt
the CPR mnemonic
of choice!
 This change has
been long in coming
 CAB does not apply CIleck IrhyUlln1{
shoc:k 11'-
to all situations indicamd '''''V
I~.' ..... /
 Healthcare
professional CPR
differs from lay
public CPR
Compression only CPR
• What about chest compression only CPR?
• AHA coined the phrase “Hands-only CPR”
• Why does this work?
• What data supports this?
– Arizona Data
– SOS Kanto
• When is it appropriate to use this?
– Technically, not in the hospital
– Technically, not for health care professionals
Compression-Only CPR
• CPP (Coronary Perfusion Pressure) is how
blood is circulated through the heart
• Happens during diastole
• CPP builds with uninterrupted compressions
• CPP drops with interruptions in compressions
• Blood in the body is completely oxygenated
at the time of cardiac arrest
• Enough O2 for several minutes of CPR
• Early in CPR ventilations add very little, they
detract from compressions and CPP
substantially!
• Bag-Mask Ventilation (BMV) is a difficult skill
• Mouth-to-mouth is even more challenging
• Most breaths are ineffective
• People are afraidto go “mouth to mouth”
• This often deters would-be rescuers
AHA 2010 ACLS Guideline
CPR: ,Quality
'Ir Pi.!sf1 hard I~ ifi1!Oh~ [5 GInn and fast (~'lOQ!mln~a'nti
ch_ reGG:l'l
alloW' complete'
iii AIIQld u"oBi$ive
ill MinTmile,rrrt.-~ptions in comp:l'eS5iol1$
v,el1~lI;atiQ1il
'.' R~tM$'COflfrpressgr 2..rtllnlilt
as aa~2'QQmpfiE!~sh;:lfil,-
~ If 1'10 adv3f1,oed aliWillV.
'.'
Vf?rt!lla:tilQnl ratio
Start CPR it! QUafilitathfilil waveform Gajif'logmphy
ill!G'Iw'lox:,!"gen - If !PETro:!. <1'0 rnm Hg" a:11temp'tt tal
III Attach
m0nitMIe;a,ftbrlllatQ'n' If<I'1IPMveC. PR qlJ~lify
• Intra-arteriaJ pr~sDJIre
- 11re!aX,~tlQnp' ha,,, (di_:oUell prue~.\,Im~4Q'
fJ1I1!ll1 Hilg. ,a.ttam,UI\)!
inlPt(;)Vle CPIH
q;II~lity
'il S~~r!lj~rn!;!oos w~tthint!a-artwial
a!teri~11
:1J;t<esSiiilrl;
Rewl1f11of !r \I~,
SpClntaneou!il
~ !1'1iOni,tO'riJ1!Q'
C~rcu_1aition (R,050]1
,I, Pulse and blood' IPfieSSUJ'le'
•SI10dk [enefD' Manufacturer Irecommernda1ii!ln
IBiphasic:
Abr!Jpt SlasiIa!ined
.' lusa·maoomum in PerOO.arnu,slibsequarlll
ifllwsase'8eQlllnd
avainalJ~e, 2 (typjca!t~yMO
IDm!S)'1iI1:er;8Ipy IVlln (120~20QI.J,); if unlsno,wCl,
mm Hg)
wses eh@lIJldbe
aeeess eQ;uM,del1l!t.~l1d hiistlli!J dQij>~~ mi1l·Ybe cOf!sideroo',
E~inephrJneevery3'~5mihut~ '. Monopliilasig; .aeg J
~nod~rone '~Drrefraotory
VlflVl Drull toorapy
Vasopressin N:1I0
'.'" IEplnep:i1rill1' 1'V110 IDo5e~'4Clurii'm
iDose~1 mg every tiafl l'eploo~ first OJ
3~5,minutes
IC!Dnalde:f Advanced of' e:plirn;~phrh'ij:
SJlloon,a' dose
Ai'rway'
'!' AmIOdsrone I,VIID DQse:: ,film oo:se::300 IITlgllbo.lllS;·~,
'GU'aotblive ~aveform,
Close:: 150 ~g,
~I1D§ll"a¢'!y' Ady;al!llced AIM~Y
.1 Sl4li':a,~lleottlc advilno!lltl3rrw~y 'or
'!lIl1Ido.trach~allllf'llubatlon
.,'i' W;aV~1iI1i
8-1 C brea!ths~no,gtiipn~llto
per w1~h,confirm !:ina'mQnl~QI'
cJlnitfnut}UJS, dhesl ~IETtube
plac~mem
minuta oomp!'JaSS1anS'
-Ftevemlblel Oauses
IHiYllovollillfll'liTa ...' Tension
- 'M~o)()ra. :pneumotli1orm<
- [Hydrogen ion -. TaIlflIiJOnllde"
- {ac.ldosTs)l ~~(Hae
- IHypo- =- TOi'~HrrtS
ltrv.lParkaJem~~a -'0 TnDl)TrlOO5Is,
Hypathem1Jat PliJlmGriliIiIiJ
Compression Depth
• Aside from early defibrillation, quality
compressions improve survival from cardiac
arrest more than anything else
• In 2010 depth increased from 1.5-2 inches to
greater than 2 inches
• Every 5 mm of increased compression depth
results in statistically significant improvement
in survival!
Compression Rate
• This was changed from ~100 compressions
per min to at least 100 compressions per min
• Studies have shown that the more
compressions the better
• “Another one Bites the Dust” vs “Staying
Alive” – sound bites?
Complete Recoil
• To maximize the effect of each compression,
the heart must be allowed to completely refill
• Molding of the chest accentuates incomplete
recoil!
CPR:
,Quality I~ ifi1!Oh~ [5 GInn and fast (~'lOQ!mln~a'nti
Pi.!sf1
'Ir ch_ reGG:l'l
hard alloW' complete'
ill MinTmile,rrrt.-~ptions in
comp:l'eS5iol1$
v,el1~lI;atiQ1il
'.' as aa~2'QQmpfiE!~sh;:lfil,-
III Attach
inlPt(;)Vle CPIH
q;II~lity
a!teri~11
:1J;t<esSiiilrl;
Rewl1f11of !r \I~,
SpClntaneou!il
IBiphasic:
ifllwsase'8eQlllnd
mm Hg)
wses eh@lIJldbe
Vasopressin N:1I0
3~5,minutes
SJlloon,a' dose
Ai'rway'
Close:: 150 ~g,
.,'i' W;aV~1iI1i
plac~mem
-Ftevemlblel Oauses
Minimizing Interruptions
• The overall number of compressions given
has been linked to survival in animal and
human studies
• As little as 5 seconds without compressions
prior to defib reduces shock efficacy
• Many of the changes in BLS and ACLS in 2005
and 2010 reflect this theme!
• Remember compressions are the MOST
IMPORTANT part of ACLS
Minimizing Interruptions
• Once a code is called or CPR initiated, only 3
things justify interrupting compressions
– Rhythm check
– Shock
– Ventilations (if synchronous)
• Interruptions usually NOT warranted in:
– Starting IVs or Central Lines
– Intubating the patient (weigh the need for this)
– Checking the rhythm AFTER a shock
CPR: ,Quality
'Ir Pi.!sf1 ifi1!Oh~ [5 GInn and fast (~'lOQ!mln~a'nti
hard I~
ch_ reGG:l'l alloW' complete'
comp:l'eS5iol1$
v,el1~lI;atiQ1il
III Attach
inlPt(;)Vle CPIH
q;II~lity
a!teri~11
:1J;t<esSiiilrl;
Rewl1f11of !r \I~,
SpClntaneou!il
IBiphasic:
ifllwsase'8eQlllnd
mm Hg)
wses eh@lIJldbe
Vasopressin N:1I0
3~5,minutes
SJlloon,a' dose
Ai'rway'
Close:: 150 ~g,
.,'i' W;aV~1iI1i
plac~mem
-Ftevemlblel Oauses
AVOID EXCESSIVE VENTILATION!
• Excessive ventilations are harmful for many
reasons:
– Impair venous return
– Decreases CPP
– Barotrauma
– Gastric insufflation
– Limited cardiac output means there is less
capacity for gas exchange. Added ventilations
are fruitless
AVOID EXCESSIVE VENTILATION!
• The proper rate is 8-10 breaths/minute if
dead, 10-12 breaths/minutes if respiratory
arrest only.
• This is 6-8 seconds/breath if dead or 5-6
seconds/breath if respirator arrest only.
• If you don’t count this out, YOU WILL
HYPERVENTILATE!
CPR: ,Quality
'Ir Pi.!sf1 GInn
ifi1!Oh~ [5 and fast (~'lOQ!mln~a'nti
hard I~
comp:l'eS5iol1$
iii AIIQld u"oBi$ive v,el1~lI;atiQ1il
'.' R~tM$' COflfrpressgraliWillV.
If 1'10 adv3f1,oed ~ aa~2'QQmpfiE!~sh;:lfil,-
2..rtllnliltas
QUafilitathfililratio
Vf?rt!lla:tilQnl
it! waveform
Start CPR
- If !PETro:!. <1'0 rnm Hg" a:11temp'tt tal
Gajif'logmphy
ill!G'Iw'lox:,!"gen
• Intra-arteriaJ
If<I'1IPMveC. PR pr~sDJIre
qlJ~lify
III Attach
m0nitMIe;a,ftbrlllatQ'n' - 11re!aX,~tlQnp' ha,,, (di_:oUell prue~.\,Im~4Q'
inlPt(;)Vle CPIH
q;II~lity
Rewl1f11of SpClntaneou!il C~rcu_1aition (R,050]1
,I, S~~r!lj~rn!;!oos
'il Pulse and blood' IPfieSSUJ'le' w~tthint!a-artwial
a!teri~11 :1J;t<esSiiilrl; !
~ r \I~, !1'1iOni,tO'riJ1!Q'
.' Abr!Jpt SlasiIa!ined ifllwsase' in PerOO 2 (typjca!t~yMO
mm Hg)
IBiphasic:
IDm!S)'1iI1:er;8Ipy IVlln lusa·maoomum
(120~20QI avainalJ~e,8eQlllnd .arnu,slibsequarlll
.J,); if unlsno,wCl,
wses eh@lIJldbe
Vasopressin N:1I0
3~5,minutes
SJlloon,a' dose
Ai'rway'
Close:: 150 ~g,
.,'i' W;aV~1iI1i
plac~mem
-Ftevemlblel Oauses
CPR: ,Quality
hard I~
comp:l'eS5iol1$
'.' AIIQld
iii R~tM$'Cu"oBi$ive v,el1~lI;atiQ1il
Oflfrpressgr 2..rtllnlilt
it! QUafilitathfilil
Vf?rt!lla:tilQnl ratiowaveform Gajif'logmphy
Start CPR - If !PETro:!. <1'0 rnm Hg" a:11temp'tt tal
ill!G'Iw'lox:,!"gen If<I'1IPMveC. PR qlJ~lify
III Attach
• Intra-arteriaJ
m0nitMIe;a,ftbrlllatQ'n' - 11re!aX,~tlQnp' ha,,, (di_:oUell prue~.\,Im~4Q'
pr~sDJIre
inlPt(;)VleSpClntaneou!il
Rewl1f11of CPIH q;II~lity C~rcu_1aition (R,050]1
.' Abr!Jpt SlasiIa!ined ifllwsase' in PerOO2
S~~r!lj~rn!;!oos
(typjca!t~yMO
'il mm Hg) w~tthint!a-artwial
a!teri~11:1J;t<esSiiilrl;~!r \I~, !1'1iOni,tO'riJ1!Q'
IBiphasic:
IDm!S)'1iI1:er;8Ipy IVlln lusa·maoomum
(120~20QI avainalJ~e,8eQlllnd .arnu,slibsequarlll
wses eh@lIJldbe
Vasopressin N:1I0
3~5,minutes
SJlloon,a' dose
Ai'rway'
Close:: 150 ~g,
.,'i' W;aV~1iI1i
plac~mem
-Ftevemlblel Oauses
Waveform Capnography
• Continuous quantitative waveform capnography
(End-Tidal CO2 or ETCO2) is now recommended
throughout the periarrest period.
• Think of this as exhaust from a car
• Capnography helps determine quality of
compressions, ET tube placement, and
appropriate ventilation rates post-resuscitation
• Many devices commercially available both as
nasal prongs and as a vent circuit interface.
Waveform Capnography
1i irierv
.. [minu aJ
te
Ro
se
*notice difference in readings as compressions improve, then

when ROSC spikes capnography readings well above normal from
sudden expulsion of CO2 build-up after ROSC
CPR: ,Quality
hard I~
comp:l'eS5iol1$
'.' AIIQld
III Attach
inlPt(;)Vle CPIH
q;II~lity
a!teri~11
:1J;t<esSiiilrl;
Rewl1f11of !r \I~,
SpClntaneou!il
SI10dk [enefD'
• IBiphasic: Manufacturer Irecommernda1ii!ln
.' (120~20QI in PerOO2 (typjca!t~yMO
ifllwsase' lusa·maoomum
IDm!S)'1iI1: mm Hg)
er;8Ipy
IVlln avainalJ~e,8eQlllnd .arnu,slibsequarlll wses
aeeess eh@lIJldbe
eQ;uM,del1l!t.~l1d hiistlli!J dQij>~~ mi1l·Ybe cOf!sideroo',
E~inephrJneevery3'~5mihut~ Drull toorapy
'. Monopliilasig; .aeg J
~nod~rone '~Drrefraotory '" IEplnep:i1rill1' N:1I0 iDose~1 mg every
VlflVl Vasopressin 1'V110 IDo5e~'4Clurii'm tiafl l'eploo~ first OJ
'.3~5,minutes
SJlloon,a' dose
Ai'rway'
Close:: 150 ~g,
.,'i' W;aV~1iI1i
plac~mem
-Ftevemlblel Oauses
Correct Shock Energy
• Monophasic vs Biphasic?
• Rectilinear vs Truncated Exponential?!?!
• Some rhythms more sensitive to electricity
• FIND THE ENERGY SETTING and TURN IT ALL
THE WAY UP!
• FIND THE SYNC BUTTON and TURN IT ON!
• Remember: Stacked shocks are long gone
CPR: ,Quality
hard I~
comp:l'eS5iol1$
'.' AIIQld
III Attach
inlPt(;)Vle CPIH
q;II~lity
a!teri~11
:1J;t<esSiiilrl;
Rewl1f11of !r \I~,
SpClntaneou!il
IBiphasic:
ifllwsase'8eQlllnd
mm Hg)
wses eh@lIJldbe
E~inephrJneevery3'~5mihut~ '.Drull toorapy .aeg J
Monopliilasig;
'" IEplnep:i1rill1' N:1I0 iDose~1 mg every 3~5,minutes
VlflVl
'. Vasopressin 1'V110 IDo5e~'4Clurii'm tiafl l'eploo~ first OJ
IC!Dnalde:f Advanced SJlloon,a' dose of' e:plirn;~phrh'ij:
'GU'aotblive
Ai'rway' ~aveform,
AmIOdsrone I,VIID DQse:: ,film oo:se::300 IITlgllbo.lllS;·~,
'!'
~I1D§ll"a¢'!y'
Close:: 150 ~g,
Ady;al!llced AIM~Y
.1 Sl4li':a,~lleottlc advilno!lltl3rrw~y 'or '!lIl1Ido.trach~allllf'llubatlon
W;aV~1iI1i
., 8-1 C brea!ths
'i' ~no,gtiipn~llto
plac~mem
-Ftevemlblel Oauses
Drugs in ACLS 2010 Guidelines
• Remember that NO DRUG has been shown to
improve outcomes in cardiac arrest.
• Epinephrine/Vasopressin doses unchanged
• Recent study on Epinephrine in cardiac arrest
shows more survival to hospitalization but
worse functional outcomes. (ALERT: this is
not yet reflected in ACLS guidelines)
Drugs in ACLS 2010 Guidelines
• Adenosine for WIDE complex tachycardia
– This is controversial
– Dose same as before (6mg, then 12mg if needed)
• Epinephrine/Dopamine for bradycardia
– Works VERY well!
– Start at 2-10 mcg/min. Titrate to effect
• Atropine for PEA/Asystole
– Downgraded again
CPR: ,Quality
hard I~
comp:l'eS5iol1$
'.' AIIQld
III Attach
inlPt(;)Vle CPIH
q;II~lity
a!teri~11
:1J;t<esSiiilrl;
Rewl1f11of !r \I~,
SpClntaneou!il
IBiphasic:
ifllwsase'8eQlllnd
mm Hg)
wses eh@lIJldbe
Vasopressin N:1I0
3~5,minutes
SJlloon,a' dose
Ai'rway'
~I1D§ll"a¢'!y'
Close:: 150 ~g,
Ady;al!llced AIM~Y
.1 Sl4li':a,~lleottlcadvilno!lltl3rrw~y 'or
'i' W;aV~1iI1i ~no,gtiipn~llto ,confirm !:ina'mQnl~QI' ~IETtube
plac~mem
., 8-1 C brea!ths per minuta w1~hcJlnitfnut}UJS, dhesl
Ftevemlblel
oomp!'JaSS1anS'
-Oauses
ltrv.lParkaJem~~a TnDl)TrlOO5Is,
-'0
Advanced Airway
• ALCS courses now teach and test on
nasopharyngeal airway (NPA) and
orophayngeal airway (OPA) placement but
NOT direct laryngoscopy for endotracheal
tube (ETT) placement.
• OPA is measured mouth to jaw
• NPA is measure nose to ear
• ALWAYS weigh the need for an advanced
airway.
CPR: ,Quality
hard I~
comp:l'eS5iol1$
'.' AIIQld
III Attach
inlPt(;)Vle CPIH
q;II~lity
a!teri~11
:1J;t<esSiiilrl;
Rewl1f11of !r \I~,
SpClntaneou!il
IBiphasic:
ifllwsase'8eQlllnd
mm Hg)
wses eh@lIJldbe
Vasopressin N:1I0
3~5,minutes
SJlloon,a' dose
Ai'rway'
Close:: 150 ~g,
'i' W;aV~1iI1i ~no,gtiipn~llto ,confirm !:ina'mQnl~QI' ~IETtube
plac~mem
Ftevemlblel Oauses
., 8-1 C brea!ths per minuta w1~hcJlnitfnut}UJS, dhesl
-oomp!'JaSS1anS' ...' Tension
-IHiYllovollillfll'l
'M~o)()ra. -. TaIlflIiJOnllde"
:pneumotli1orm<
~~(Hae
iTa
- [Hydrogen ion {ac.ldosTs)l =- TOi'~HrrtS
- IHypo-ltrv.lParkaJem~~a -'0 TnDl)TrlOO5Is,
PliJlmGriliIiIiJ
- Hypathem1Jat -- Thll'oml;tosis.
leoronacy
Intraosseous Line
• AHA, European Resuscitation Council, and
ILCOR all endorse the IO approach
• “if intravenous access is difficult or
impossible the provider should consider the
intraosseous route”
• Several commercially available products:
– Standard needle
– BIG gun
– EZ-IO
Steps for IO insertion
• Steps for proximal tibia
insertion are illustrated
on the inside of each
• driver case.
Proximal humerus and
distal tibia may also be
• used.
Pressure infusion on
conscious patients will
require 20-40mg. 2%
Lidocaine infused after
starting IO (1-2cc’s)
Adult Post-Cardiac Arrest
Immediate Care
1
r
Return of Spontaneous Circulation (ROSC)
I Doses/Detail
s
Ventilation/Oxygenation
Avoid excessive ventilation.
2 It
Start at 10-12 breaths/min
and titrate to target PETC02
Optimize ventilation and of 35-40 mm Hg.
oxygenation When feasible, titrate Flo
to minimum necessary t02
•• Consider
Maintain oxygen
advancedsaturation
airway ~94%
and waveform capnography achieve Sp02 ~94%.
• Do not hyperventilate
IV Bolus
1-2 L normal saline
or lactated Ringer's.
3 If inducing hypothermia,
may use 4°C fluid.
Treat (SBP <90 mm Hg)
hypotension Epinephrine IV Infusion:
0.1-0.5 mcg/kg per minute
• IViIO bolus (in 70-kg adult: 7-35 mcg
•• Vasopressor infusioncauses
Consider treatable per minute)
• 12-Lead ECG Dopamine IV Infusion:
5-10 mcg/kg per minute
4 Norepinephrine
5
IV Infusion:
I No Follow 0.1-0.5 mcg/kg per minute
Consider hypothermi commands
I induced a ?
(in 70-kg adult: 7-35 mcg
per minute)
I Reversible Causes
7 6 + Yes
-
-
Hypovolemia
Hypoxia
•I
Yes STEMI Hydrogen ion (acidosis)
-
Coronary OR
- Hypo-/hyperkalemia
reperfusion high suspicion of AMI
- Hypothermia
I - Tension pneumothorax
•
- Tamponade, cardiac
8 ' No Toxins
-
Thrombosis, pulmonary
Advance
d
critica care
l I -
- Thrombosis, coronary
© 2010 Amp.rir.::Jn Haar+ A!':!':or.i::Jtion

Oxygenation
• Excessive Oxygen in unnecessary and may be
harmful
• Can act to vasoconstrict coronary arteries
• After ROSC, O2 sats should be monitored and
titrated to ≥94%
• Supplementary O2 is NOT needed if no
respiratory distress or when O2 sat is ≥94% in
periarrest or ROSC patients.
Adult Post-Cardiac Care
Immediate Arrest
1
r
I Doses/Detail
s
2 Avoid excessive ventilation.
It
Optimize ventilation and and titrate to target PETC02
oxygenation of 35-40 mm Hg.
When feasible, titrate Flo
•• Consider
Maintain oxygen
advancedsaturation
airway ~94%
and waveform capnography to minimum necessary t02
achieve Sp02 ~94%.
IV Bolus
1-2 L normal saline
3
If inducing hypothermia,
Treat (SBP <90 mm Hg) may use 4°C fluid.
• IViIO bolus
• 12-Lead ECG
Dopamine IV Infusion:
5 4 Norepinephrine
IV Infusion:
II No Follow 0.1-0.5 mcg/kg per minute
Consider induced hypothermia commands
I ?
per minute)
I
+
Reversible Causes
Yes
6 - Hypovolemia
7
- Hypoxia
•I
-
Coronary OR
- Hypothermia
•
8 ' No Toxins
-
Advance
d
critica care
l I -

Therapeutic Hypothermia
• 2 landmark multi-center RCT’s showed a
HUGE benefit to therapeutic hypothermia,
many other smaller studies have followed
• Clear benefit for comatose survivors of
witnessed, v-fib arrest
• Other types of arrest are less clear
• Use your judgment, consult with the experts
Therapeutic Hypothermia
• Goal temperature is 33 degrees celcius
• Cool ASAP for 24 hrs
• Your hospital/ICU should have a protocol, if
not you can easily find one online.
Adult Post-Cardiac Care
Immediate Arrest
1
r
I Doses/Detail
s
2 Avoid excessive ventilation.
It
Optimize ventilation and and titrate to target PETC02
oxygenation of 35-40 mm Hg.
When feasible, titrate Flo
•• Consider
Maintain oxygen
advancedsaturation
airway ~94%
and waveform capnography to minimum necessary t02
achieve Sp02 ~94%.
IV Bolus
1-2 L normal saline
3
If inducing hypothermia,
Treat (SBP <90 mm Hg) may use 4°C fluid.
• IViIO bolus
• 12-Lead ECG
Dopamine IV Infusion:
5 4 Norepinephrine
IV Infusion:
I No Follow
Consider hypothermi 0.1-0.5 mcg/kg per minute
commands
I induced a ?
per minute)
I
+
Reversible Causes
Yes
6 - Hypovolemia
7
- Hypoxia
•I
-
Coronary OR
- Hypothermia
•
8 ' No Toxins
-
Advance
d
critica care
l I -

Strongly Consider STEMI
• As many as ½ of cardiac arrest patient are
due to coronary ischemia.
• The post resuscitation EKG may not show a
STEMI
• Consult cards on every one
THE END
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American Heart Association 2010 Acls Guidelines:: What Every Clinician Needs To Know

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AMERICAN HEART

ASSOCIATION 2010 ACLS

 ABC is not longer

*notice difference in readings as compressions improve, then

© 2010 Amp.rir.::Jn Haar+ A!':!':or.i::Jtion

© 2010 Amp.rir.::Jn Haar+ A!':!':or.i::Jtion

© 2010 Amp.rir.::Jn Haar+ A!':!':or.i::Jtion

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