On Monday 18th October the rules that govern Resuscitation changed. We are currently updating our videos and they will be live shortly. The changes are as follows:
Adult basic life support
The following changes in the basic life support (BLS) guidelines have been made to reflect the importance placed on chest compression, particularly good quality compressions, and to attempt to reduce the number and duration of pauses during chest compression:
- When obtaining help, ask for an automated external defibrillator (AED), if one is available.
- Compress the chest to a depth of 5-6 cm and at a rate of 100-120 min.
- Do not stop to check the victim or discontinue CPR unless the victim starts to show signs of regaining consciousness, such as coughing, opening his eyes, speaking, or moving purposefully AND starts to breathe normally.
- Teach CPR to laypeople with an emphasis on chest compression, but include ventilation as the standard, particularly for those with a duty of care.
The use of Automated External Defibrillators
There are no major changes to the sequence of actions for AED users in Guidelines 2010. The following changes are aimed mainly at increasing the use of AEDs along with clarification on when to stop CPR:
- An AED can be used safely and effectively without previous training; its use should not be restricted to trained rescuers. Training should however be encouraged to help improve the time to shock delivery and correct pad placement
- Short video/computer self-instruction courses, with minimal or no instructor coaching, combined with hands-on practice can be considered as an effective alternative to instructor-led BLS and AED courses. Such courses should be validated to ensure that they achieve equivalent outcomes to instructor-led courses (ProTrainings video e-learning systems)
- When using an AED minimise interruptions in chest compression. Do not stop to check the victim or discontinue CPR unless the victim starts to show signs of regaining consciousness, such as coughing, opening his eyes, speaking, or moving purposefully AND starts to breathe normally.
Pre-hospital cardiac arrest
A pre-hospital chapter has been included for the first time in the RC(UK) Guidelines. The chapter covers the following resuscitation topics of specific relevance to the pre- hospital emergency medical services (EMS):
- Telephone-advised cardiopulmonary resuscitation (CPR)
- CPR versus defibrillation first
- Pre-hospital airway management
- Rules for stopping resuscitation.
Paediatric basic life support
Changes in paediatric life support guidelines have been made partly in response to new scientific evidence, and partly to simplify them in order to assist teaching and retention. As in the past, there remains a paucity of good-quality evidence specifically on paediatric resuscitation, and some conclusions have had to be drawn from experimental work or extrapolated from adult data.
Although ventilation remains a very important component of CPR in asphyxial arrest, rescuers who are unable or unwilling to provide this should be encouraged to perform at least compression-only CPR. A child is far more likely to be harmed if bystanders do nothing at all.
Chest compressions are frequently too shallow, so there has been a subtle, but important, change in the instruction on chest compressions from ‘approximately one third’ to ‘at least one third’ of the AP diameter of the chest. The mean one-third compression depths for infants and children are 4 and 5 cm respectively. In order to be consistent with the adult BLS guidelines the recommended compression rate is now 100 – 120 min.
Studies have shown that compression-only CPR may be as effective as combined ventilation and compression in the first few minutes after non-asphyxial arrest. However, chest compression combined with rescue breaths is the method of choice for CPR by trained lay rescuers and professionals and should be the basis for lay-rescuer education. Lay rescuers who are unable or unwilling to provide rescue breaths, should be encouraged to give chest compressions alone. When advising untrained laypeople by telephone, ambulance dispatchers should give instruction on compression-only CPR.
Resuscitation of children and victims of drowning
Both ventilation and compression are important for victims of cardiac arrest when the oxygen stores become depleted: about 2 – 4 min after collapse from ventricular fibrillation (VF), and immediately after collapse for victims of asphyxial arrest. Previous guidelines tried to take into account the difference in causation, and recommended that victims of identifiable asphyxia (drowning; trauma; intoxication) and children should receive 1 min of CPR before the lone rescuer left the victim to get help. But most cases of sudden cardiac arrest out of hospital occur in adults and are of cardiac origin due to VF (even though many of these will have changed to a non-shockable rhythm by the time of the first rhythm analysis). These additional recommendations, therefore, added to the complexity of the guidelines whilst applying to only a minority of victims.
Many children do not receive resuscitation because potential rescuers fear causing harm. This fear is unfounded; it is far better to use the adult BLS sequence for resuscitation of a child than to do nothing. For ease of teaching and retention, laypeople
should be taught to use the adult sequence for children who are not responsive and not breathing normally, with the single modification that the chest should be compressed by one third of its depth. However, the following minor modifications to the adult sequence will make it even more suitable for use in children:
- Give 5 initial rescue breaths before starting chest compressions (adult BLS sequence of actions 5B).
- If you are on your own, perform CPR for 1 min before going for help.
- Compress the chest by one third of its depth. Use two fingers for an infant under 1 year; use one or two hands for a child over 1 year as needed to achieve an adequate depth of compression.
The same modifications of five initial breaths, and 1 min of CPR by the lone rescuer before getting help, may improve outcome for victims of drowning. This modification should be taught only to those who have a specific duty of care to potential drowning victims (e.g. lifeguards). If supplemental oxygen is available, and can be brought to the victim and used without interruption in CPR (e.g., by attaching to a resuscitation face mask), it may be of benefit.
Drowning is easily identified. It can be difficult, on the other hand, for a layperson to recognise when trauma or intoxication has caused cardiorespiratory arrest. If either cause is suspected the victim should be managed according to the standard BLS protocol.
Considerable practice and skill are required to use a bag and mask for ventilation. The lone rescuer has to be able to open the airway with a jaw thrust whilst simultaneously holding the mask to the victim’s face. It is a technique that is appropriate only for lay rescuers who work in highly specialised areas, such as where there is a risk of cyanide poisoning or exposure to other toxic agents. There are other specific circumstances in which non-healthcare providers receive extended training in first aid, which could include training, and retraining, in the use of bag-mask ventilation. The same strict training that applies to healthcare professionals should be followed and the two-person technique is preferable.
Mouth-to-tracheostomy ventilation may be used for a victim with a tracheostomy tube or tracheal stoma who requires rescue breathing.
Mouth-to-nose ventilation is an effective alternative to mouth-to-mouth ventilation. It may be considered if the victim’s mouth is seriously injured or cannot be opened, if the rescuer is assisting a victim in the water, or if a mouth-to-mouth seal is difficult to achieve.
Agonal gasps are present in up to 40% of cardiac arrest victims.10 Therefore laypeople should be taught to begin CPR if the victim is unconscious (unresponsive) and not breathing normally. It should be emphasised during training that agonal gasps occur commonly in the first few minutes after sudden cardiac arrest; they are an indication for starting CPR immediately and should not be confused with normal breathing.
More details to follow shortly or download the following:
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