Accordingly, compressions should be given at a target (mean) rate of 80/min. For assessment, however, a range of 60-100 compressions/min would be accept- able. This is the rate or speed at which compressions should be undertaken, not the absolute number of compressions delivered within a given minute. BMJ: first published as 10.1136/bmj.306.6892.1589 on 12 June 1993. Downloaded from It is essential to combine ventilation with chest compression in order that the blood, which is being artificially circulated, contains enough oxygen. In an unconscious adult the rescuer should aim to press down some 4-5 cm and apply only enough pressure to achieve this. At all times the pressure should be firm, controlled, and applied vertically. Erratic or violent action is dangerous. Try to spend about the same time in the compressed phase as in the released phase. As the chances are remote that effective spontaneous cardiac action will be restored by cardiopulmonary *@d~~~~ resuscitation without other techniques of advanced life taktw fou .,,seons Eac seuec of IO breaths:E support (including defibrillation),' time should not be wasted by further checks for a pulse. If, however, the wiltereor tae abo 40tto 60 econds casualty makes a movement or takes a spontaneous Theat tiin of exiato isnt crticAl wait fory* breath check the carotid to see whether the heart FIG 5-Method ofturning pulse casualty to recovery position is beating; take no more than five seconds. Otherwise do not interrupt resuscitation. before giving another inflation This should normally Much of the content of this article has been published in take two to four seconds. Each sequence of 10 breaths Resuscitation.2 will therefore take about 40 to 60 seconds. Members of the working group were: Stig Holmberg (Sweden; The exact timing of expiration is not critical; wait for chairman), Anthony Handley (England; secretary), Jan the chest to fall, then give another inflation. Bahr (Germany), Peter Baskett (England), Leo Bossaert (Belgium), Douglas Chamberlain (England), Wolfgang Dick CHEST COMPRESSION (Germany), Ank van Drenth (Netherlands), Lars Ekstrom There is no evidence that an initial precordial (chest) (Sweden), Rudolf Juchem (Germany), Dietrich Kettler thump improves survival in an unwitnessed cardiac (Germany), Andrew Marsden (Scotland), Oliver Moeschler arrest. On the other hand, a witnessed or monitored (Switzerland), Koen Monsieurs (Belgium), Paul Petit (France), Hribar Primoz (Bosnia), Jurgen Schuttler cardiac arrest may successfully be terminated by a (Germany). thump, and a thump is recommended as part of the advanced life support protocol.' 1 European Resuscitation Council Working Party. Adult advanced cardiac life There is no convincing evidence that success of support: the European Resuscitation Council guidelines 1992 (abridged). BMJ 1993;306:1589-93. cardiopulmonary resuscitation is influenced by the rate 2 Basic Life Support Working Party of the European Resuscitation Council. http://www.bmj.com/ of chest compressions within the range 60-100/min. Guidelines for basic life support. Resuscitation 1992;24:103-10. Adult advanced cardiac life support: the European Resuscitation Council guidelines 1992 (abridged) on 24 September 2021 by guest. Protected copyright. European Resuscitation Council Working Party The European Resuscitation Council, established in support at its first scientific congress in 1992. Three 1990, is committed to saving lives by improving principles were held to be important in the production standards of cardiopulmonary resuscitation across of the guidelines. The first was a willingness to review Europe and coordinating the activities of interested comprehensively the evidence justifying existing organisations and individuals. In this regard the recommendations. The second was an emphasis on council has successfully brought together physicians minimising delay in delivering defibrillating shocks and surgeons from eastern and western Europe to the victims of ventricular fibrillation. The third was and, in addition, has established relations with the need for simplicity in treatment algorithms. In the American Heart Association and equivalent addition, the guidelines were to be appropriate for organisations in Canada, Australia, and South semiautomated or automated defibrillators and for use Africa. A main objective ofthe European Resuscita- both in hospital and in pre-hospital settings. tion Council is to produce guidelines for cardio- Draft guidelines were submitted for comment to European Resuscitation pulmonary and cerebral resuscitation, and in this representatives of national societies with affiliation to Council Members ofthe working paper members ofa working party of 14 experts from the European Resuscitation Council. After appropriate party are listed at the end of 11 countries set out an abridged version of the modifications they were approved by the executive this report. council's guidelines for adult advanced cardiac life committee of the council. The guidelines have been support. The council hopes that the guidelines and published in preliminary form,' 2 together with papers Correspondence to: accompanying algorithms will serve as a ready summarising the scientific evidence on which they Dr Douglas Chamberlain, use "how to do it" for ordinary practitioners and were based.3'2 This paper sets out an abridged version Royal Sussex County paramedics inside and outside hospital. of the guidelines for adult advanced cardiac life Hospital, Brighton support aimed at promoting their implementation. BN2 5BE. The European Resuscitation Council presented Abridged and complete versions will also be published BMJ 1993;306: 1589-93 guidelines for adult basic and advanced cardiac life in other European joumals. BMJ VOLUME 306 12 JUNE 1993 1589 The arrhythmias ofcardiac arrest 200 J, 200 J, and 360 J. Provided that these shocks can Cardiac arrest is the cessation of cardiac mechanical be delivered quickly (within 30 to 45 seconds), then activity, confirmed by the absence of a detectable the sequence should not be interrupted by basic life pulse, unresponsiveness, and apnoea (or agonal support measures. Ideally, for safety, the electrodes respirations). In adults the commonest cause is should be left on the chest when rapid sequences of BMJ: first published as 10.1136/bmj.306.6892.1589 on 12 June 1993. Downloaded from primary ischaemic heart disease. Cardiac arrest may be shocks are given. Some check of rhythm or pulse associated with any of four heart rhythms: ventricular must be made after each shock, the method depending fibrillation, pulseless ventricular tachycardia, asystole, on the type ofequipment being used. or electromechanical dissociation. With manual defibrillators a pulse should be sought. Ventricular fibrinlation is by far the commonest If it is absent the defibrillator should be recharged primary rhythm of cardiac arrest, especially in victims without waiting for the monitor tracing to return of sudden, unheralded cardiac death. Pulseless because the delay may be appreciable. Electrocardio- ventricular tachycardia may occur first, but usually graphic confirmation on the monitor is desirable, deteriorates rapidly to ventricular. fibrillation. The however, immediately before the next shock. With two conditions are treated identically. If managed automated defibrillators feeling the pulse delays the appropriately and promptly most patients with these diagnostic algorithm by introducing artefact. For most rhythms can survive to hospital discharge, but only shocks reliance should therefore be placed on the rarely can these conditions be met. Prospects for machine, which will indicate whether another shock is survival decrease by roughly 5% a minute even with required. Palpation is restricted to the start of each effective basic life support, and delay to defibrillation is loop-once every third defibrillator discharge. If the the most important determinant ofsuccess or failure. time to charge the defibrillator is unduly prolonged one Asstole is the primary rhythm in up to a quarter of or two sequences of basic life support (if there are two cardiac arrests in hospital and 10% of those outside rescuers: five chest compressions to one breath) should hospital. It is seen most commonly, however, as the be given between shocks. end result in patients with ventricular fibrillation who When the first three shocks are unsuccessful the have not been resuscitated successfully. prospects of recovery are not hopeless, and attempts Electromechanical dissociation is a term that implies should continue ifthis strategy is appropriate clinically. absence of mechanical activity or undetectable activity As restoration of coordinated rhythm will inevitably be in the presence of a continuing coordinated waveform delayed, if it occurs at all, the priority must change to in the electrocardiogram. It is diagnosed infrequently preserving cerebral and myocardial perfusion by the in pre-hospital victims of cardiac arrest (except when best possible basic life support. caused by trauma), partly because a coordinated electrocardiographic waveform can persist only PROCEDURE WHEN FIRST THREE SHOCKS HAVE FAILED transiently in the absence of coronary flow. Patients If not achieved already, brief attempts should be with electromechanical dissociation or asystole usually made to intubate the patient and gain intravenous have a survival rate less than 5% when the condition is access. In most settings these procedures will be caused by heart disease. Higher survival rates have