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The new adult resuscitation guidelines
(Practice Nurse Via Thomson Dialog NewsEdge)
Rob Morrison RGN, BSc (Hons), PGCE is Senior Resuscitation Officer at Darent Valley Hospital, Dartford, Kent
The International Liaison Committee on Resuscitation (ILCOR) has reached consensus about the scientific findings and new guidelines were released at the end of 2005.
Most UK hospitals are now following these guidelines and all areas of primary care should be doing the same. The guidelines represent the most effective and easy-to-teach resuscitation techniques that current knowledge, research and experience can provide.
All healthcare staff should be attempting to update their current knowledge and skills. The full 2005 Guidelines, along with posters of the new treatment algorithms, can be accessed at the Resuscitation Council (UK) website.1
resuscitation in the community
All healthcare professionals who work in the community may be required to resuscitate a victim of cardiopulmonary arrest.
Sudden cardiac arrest is a leading cause of death in Europe, affecting about 700,000 individuals a year.2 Underlying heart disease is the most common cause of such arrest. A rhythm likely to respond to attempted defibrillation is present in 90% of patients. About 60% of those who arrest at home and 75% of those who arrest on surgery premises subsequently survive to leave hospital after early defibrillation by a trained person.1
Quality compressions and ventilations will improve the chances of a successful outcome by extending the window of time in which defibrillation can be effective. However, for every minute's delay in getting the defibrillator to the patient, survival drops by 7-10%.
The collapse-to-shock interval can be greatly reduced if a practice can purchase an advisory defibrillator known as an automated external defibrillator (AED). The new generation of AEDs are relatively inexpensive, easy to use and require minimal maintenance. Most now available also perform self-checks and advise if maintenance is required. Practices should now have or be purchasing an AED.
Basic equipment recommendations
Not all practices will have access to an AED but no practice should be expecting their staff to perform mouth-to-mouth on duty. Therefore, the minimum resuscitation equipment should be a pocket mask, oxygen and a suction device. Attachments for oxygen should be available on the pocket mask, and a suction device is needed because of the increased risk of vomiting during ventilation.
These items are inexpensive and simple devices such as disposable pocket masks and handheld suction pumps are widely available. Additional items can be considered depending on the skills of the staff.
Remember that resuscitation equipment in general practice will rarely be used. Having lots of equipment is not always good and can complicate an emergency situation. The equipment discussed is adequate and will be easy to use and maintain. It should be kept together in something like a grab-bag, and all staff must know where it is located.
Training and practical aspects
The minimum standard for staff training should be proficiency in basic life support (BLS) with a pocket mask. The new Resuscitation Council (UK) Adult Basic Life Support Algorithm is shown in Figure 1. Most of the community team should also be capable of using an AED, and the new AED algorithm is particularly relevant to appropriately equipped practices (see Figure 2).
The importance of quality chest compressions is now clear. To make compressions simpler, it has been shown that the correct hand position can be found more quickly if rescuers are taught to: 'place the heel of your hand in the centre of the chest with the other hand on top'. Provided that the teaching includes a demonstration of placing the hands in the middle of the lower half of the sternum, this should help non-healthcare staff learn and retain this skill.3
In adults, we now start with compressions first, as the patient is already likely to have some oxygen in the blood.
community practice with an AED
This overview is designed for clinical staff at work and it is assumed that assistance is available. If this is not the case, certain actions will need adjustment.
If a patient collapses in a primary care setting, after an initial check for responsiveness and a shout for help, the airway should be checked and opened. The healthcare professional should check for any signs of life. If skilled enough, this check can include palpation of the carotid pulse. Cardiac arrest is confirmed if no life signs appear present or a definite pulse cannot be located.
Note that agonal breathing (occasional gasps, slow, laboured, or noisy breathing) is common in the early stages of cardiac arrest - it is a sign of arrest and must not be mistaken for a sign of life.
Once cardiac arrest is confirmed, one person should immediately start compressions. They should continue as others call 999 for an ambulance and collect the resuscitation equipment. If only one member of staff is present, they should leave the patient in order to access help and equipment.
Once ventilation equipment is ready, a ratio of 30 compressions and 2 ventilations should be followed. If any short delays occur either in arrival of the resuscitation equipment or setup of equipment, uninterrupted chest compressions should continue. This is a suitable short-term procedure until equipment is set up and ready to use. Any period of no activity could be detrimental to the patient.
To prevent fatigue, the person performing compressions should be changed every 2 minutes.
Before commencing ventilation, the airway should be checked and opened. Attach high-flow oxygen to a pocket mask and start ventilation. The second person should perform chest compressions. The third person to arrive should confirm that oxygen is connected and that suction is turned on and is ready for use.
Most practices should now have a defibrillator with an AED function. The AED should be turned on immediately if the patient has not responded to the initial compressions or if someone has confirmed a carotid pulse is absent. Once turned on, the AED voice prompts should be followed. Defibrillation and CPR (30:2) should be carried out as instructed by the voice prompts. This ensures that all patients in a shockable rhythm receive early first responder defibrillation.
The staff should continue resuscitation and start to consider the possible cause of the cardiac arrest. One member of staff should be designated to give a handover to the arriving ambulance crew. If any medical notes exist for the casualty, they should be located.
New AED settings
Experimental studies show that relatively short interruptions in chest compressions to deliver rescue breaths or perform rhythm analysis are associated with reduced survival.4,5 An AED can create long pauses to compressions, especially when performing three shocks, and this is one reason for a change in the shocking sequence. The new guidelines recommend a change in the sequence of defibrillation, in particular from the three 'stacked' shocks, to single shocks followed immediately by 2 minutes of CPR before rhythm assessment. This is to minimise the 'no bloodflow' time.
This new shocking sequence has implications for any practice with an AED. AEDs will need to be reconfigured with the new guidelines. In most cases, this requires advice from the manufacturer/supplier as the internal settings of the AED will need to be accessed. The BLS/AED subcommittee of the Resuscitation Council (UK) recommends that, until such time as AEDs and training AEDs are re-programmed, AEDs designed to conform to the earlier guidelines should continue to be used according to their current voice prompts.6
Conclusion
Quality CPR and early defibrillation save lives, particularly in the community setting where more sudden cardiac deaths occur. However, recent evidence indicates that unnecessary interruptions to chest compressions occur frequently both in and out of hospital.7-9
The importance of minimising interruptions to chest compression cannot be over emphasised. Coronary blood flow diminishes rapidly if chest compressions are interrupted, and this is detrimental to patient outcome. The new guidelines have attempted to address this in many ways, the most obvious being a new compression and ventilation ratio of 30:2.
The publication of the new treatment recommendations does not imply that previous clinical care was unsafe or ineffective but we all should now be actively updating our practice and equipment to offer the best for future patient care. The Resuscitation Council (UK) has acknowledged that, as the transition is made, there will inevitably be some variation in practice between individuals and healthcare organisations. The long-term outcome is likely to show significant improvements to resuscitation practice and, it is hoped, cardiac arrest outcomes.
Points for Practice
Be aware of the key clinical changes
In adult cardiac arrest, start with compressions first
Compression-ventilation (CV) ratio of 30:2
If you are not able, or are unwilling, to give rescue breaths, give chest compressions only
Reprogramme AEDs to follow the new AED algorithm
REFERENCES
1. Cardiopulmonary Resuscitation Guidance for clinical practice and training in primary care. Resuscitation Council, 2001. Available at www.resus.org.uk/pages/cpatpc.htm
2. Sans S, Kesteloot H et al. Eur Heart J 1997; 18:1231-48.
3. Handley AJ. Resuscitation 2002; 53: 29-36.
4. Berg RA, Sanders AB, Kern KB, et al. Circulation 2001; 104: 2465-70.
5. Kern KB, Hilwig RW et al. Circulation 2002; 105: 645-9.
6. Resuscitation Council. Statement on the use of AEDs (Interim period until AED has been reprogrammed). London: Resuscitation Council, 2005. Available at www.resus.org.uk/pages/aedstat.htm
7. Wik L, Kramer-Johansen J et al. JAMA 2005; 293: 299-304.
8. Abella BS, Alvarado JP, Myklebust H et al. JAMA 2005; 293: 305-10.
9. Abella BS, Sandbo N, Vassilatos P et al. Circulation 2005; 111: 428-34.
further reading
Resuscitation Guidelines 2005. Resuscitation Council (UK), London 2005.
Advanced life support course. Provider Manual, 5th Edition. Resuscitation Council (UK), London 2006.
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