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Basic Life Support 1 1.2 Advanced Life Support 5 RESUSCITATION Edited by Conor Deasy SECTION 1 1.1 Basic life support 1 1.2 Advanced life support 5 1.1 Basic life support Sameer A. Pathan compressions and rapid defibrillation, which ESSENTIALS significantly improves the chances of survival from ventricular fibrillation (VF) in OHCA.1–3 CPR 1 A patient with sudden out-of-hospital cardiac arrest (OHCA) requires activation of plus defibrillation within 3 to 5 minutes of collapse the Chain of Survival, which includes early high-quality cardiopulmonary resuscitation following VF in OHCA can produce survival rates (CPR) and early defibrillation. The emergency medical dispatcher plays a crucial and as high as 49% to 75%.5–7 Each minute of delay central role in this process. before defibrillation reduces the probability of survival to hospital discharge by 10% to 12%.2,3 2 Over telephone, the dispatcher should provide instructions for external chest The final links in the Chain of Survival are effec- compressions only CPR to any adult caller wishing to aid a victim of OHCA. This approach tive ALS and integrated post-resuscitation care has shown absolute survival benefit and improved rates of bystander CPR. targeted at optimizing and preserving cardiac 8 3 In the out-of-hospital setting, bystanders should deliver chest compressions to any and cerebral function. unresponsive patient with abnormal or absent breathing. Bystanders who are trained, able, and willing to give rescue breaths should do so without compromising the main focus on high quality of chest compressions. Development of protocols Any guidelines for BLS must be evidence based 4 Early defibrillation should be regarded as part of Basic Life Support (BLS) training, as and consistent across a wide range of providers. it is essential to terminate ventricular fibrillation. Many countries have established national com- mittees to advise community groups, ambulance 5 There is strong emphasis on the implementation of public-access defibrillation services and the medical profession of appropri- programs, which include the use of automated external defibrillators by untrained or ate BLS guidelines. Box 1.1.1 lists the national asso- minimally trained lay rescuers in public areas. ciations that make up the International Liaison Committee on Resuscitation (ILCOR). The ILCOR group meets every 5 years to review the BLS This chapter outlines an approach to BLS that and ALS guidelines and to evaluate the scientific Introduction can be delivered by any rescuer while awaiting evidence that may lead to changes. Basic Life Support (BLS) aims to maintain respira- the arrival of emergency medical services (EMS) tions and circulation in the cardiac arrest victim. or medical expertise able to provide Advanced BLS’s major focus is on CPR with minimal use Life Support (ALS) (see Chapter 1.2). of ancillary equipment. It includes chest com- Box 1.1.1 Membership of the International pressions with or without rescue breathing Chain of Survival Liaison Committee on Resuscitation 2015 and defibrillation with a manual or automated The Chain of Survival is the series of linked American Heart Association (AHA) external defibrillator (AED). BLS can be success- actions taken in treating a victim of sudden European Resuscitation Council (ERC) fully performed immediately by any rescuer with cardiac arrest.4 The first steps are early recogni- Heart and Stroke Foundation of Canada (HSFC) Resuscitation Council of Southern Africa (RCSA) little or no prior training or experience using tion of an individual at risk of or in active cardiac Australian and New Zealand Committee on dispatcher-assisted telephone instructions in the arrest and an immediate call to activate help from Resuscitation (ANZCOR) OHCA. BLS has proven value in aiding the survival EMS. This is followed by early commencement InterAmerican Heart Foundation (IAHF) Resuscitation Council of Asia (RCA) of neurologically intact victims.1–3 of CPR with an emphasis on high-quality chest 1 1.1 BASIC LIFE SUPPORT as it is available, and prompts are followed if it is Basic Life Support automatic or semiautomatic. Change to the adult Basic Life Support in 2015 D Dangers? A significant change to the adult BLS in the ILCOR 2010 resuscitation guidelines was the recommen- dation for a Compressions, Airway, Breathing Responsive? (CAB) sequence instead of an Airway, Breathing, R Compressions (ABC) sequence. This was aimed at minimizing any delay in initiating chest compres- sions, particularly when the sudden collapse is S Send for help witnessed and likely of cardiac origin. In the 2015 guidelines, the ILCOR task force differed from regional resuscitation councils in deciding to use A Open airway the CAB or ABC sequence, as limited literature exists to make any single recommendation. Regional variations B Normal breathing? There are regional variations in the interpretation and incorporation of opening the airway within the BLS algorithm. In the European Resuscita- Start CPR tion Council (ERC) and the ARC with the NZRC C 30 compressions : 2 breaths algorithm, opening the airway comes before assessment of breathing followed by compres- sion if required. This effectively preserves the ABC sequence to avoid confusion, whereas the Attach Defibrillator (AED) American Heart Association (AHA) Resuscita- as soon as available and follow its prompts D tion Guidelines 2015 continue to advise a CAB sequence for CPR. The ILCOR 2015 universal BLS algorithm with Continue CPR until responsiveness or ARC and NZRC considerations is discussed in the normal breathing return remainder of this chapter. Check for response and send for help The patient who has collapsed is rapidly assessed FIG. 1.1.1 Australian Resuscitation Council and New Zealand Resuscitation Council Basic Life Support flowchart. AED, Automated external defibrillator; CPR, cardiopulmonary resuscitation. (Reproduced from to determine whether he or she is unresponsive https://resus.org.au/guidelines/flowcharts-3/) and not breathing normally, indicating pos- sible cardiorespiratory arrest. For an untrained rescuer, this can be sequentially assessed by Revision of the Basic Life Support http://www.resus.org.au/policy/guidelines/ and a gentle ‘shake and shout’ and observation of guidelines, 2015 http://www.nzrc.org.nz/guidelines/ respectively. the patient’s response rather than by looking The most recent revision of the BLS guidelines specifically for signs of life (which was deemed occurred in 2015 and followed a comprehensive potentially confusing). The rescuer can then evaluation of the scientific literature for each DRSABCD approach to Basic Life assess the unresponsive patient for absent or aspect of BLS. Evidence evaluation worksheets Support inadequate breathing. were developed and were then considered by A flowchart for the initial evaluation and provi- If cardiac arrest is assumed, the rescuer ILCOR (available at http://circ.ahajournals.org/ sion of BLS for the collapsed patient is shown in should immediately telephone the EMS (call content/132/16_suppl_1/S40). The final recom- Fig. 1.1.1. This is based on a DRSABCD approach, first) and initiate chest compressions as advised 8 mendations were published in late 2015. the letters of which stand for Dangers? Respon- by the dispatcher to initiate BLS care. A trained sive? Send for help; open Airway; normal rescuer or health care provider may check for Australian Resuscitation Council and Breathing? start CPR; and attach Defibrillator. This unresponsiveness and abnormal breathing at the New Zealand Resuscitation Council process therefore includes the recognition that a same time and then activate the EMS or cardiac Basic Life Support guidelines patient has collapsed and is unresponsive, a safe arrest team. Each national committee endorsed the guide- approach to checking for danger and immedi- The health care rescuers may commence lines with minor regional variations to take into ately sending for help to activate the emergency CPR with ventilation for approximately 2 min- account local practices. The recommendations medical response team. This is followed by open- utes before calling the EMS (CPR first) when the of the Australian Resuscitation Council (ARC) ing the airway and briefly checking for abnormal collapse is due to suspected airway obstruction combined with those of the New Zealand or absent breathing, with rapid commencement (choking) or inadequate ventilation (drowning, Resuscitation Council (NZRC) on BLS were of chest compressions and rescue breaths if the hanging, etc.) or for infants and children up to published jointly in 2016 and are available at pulse is absent. A defibrillator is attached as soon 18 years of age. 2 1.1 BASIC LIFE SUPPORT 1 RESUSCITATION Assessment of airway and breathing effectiveness of the chest compressions. There Passive ventilation with chest recoil Make an assessment of the airway if a patient has is strong emphasis on delivering high-quality The rationale for hands-only or chest compres- collapsed and is apparently unconscious. Place chest compressions: rescuers should push hard sion–only CPR is that if the airway is open, the patient supine if face down and look for any to a depth of at least 5 cm (or 2 inches) at a rate passive ventilation may provide some gas signs of obvious airway obstruction. A trained of approximately 100 to 120 compressions per exchange during the recoil phase of the chest lay rescuer or health care rescuer may open the minute, allowing full chest recoil by avoiding compressions. However, the passive ventilation airway using the head tilt–chin
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