Guidelines on Basic Life Support – Resuscitation Council (UK) 2015

Guidelines Basic Life Support

On 15th October 2015 the Resuscitation Council UK (RCUK) issued the latest guidelines on Basic Life Support. The Basic Life Support protocol in the UK remains broadly unchanged and still consists of a combination of chest compressions and Rescue breaths at a rate of 30:2, with the depth and frequency of compressions also remaining unchanged at 5-6cm depth and a compression rate of 100-120 compressions a minute.

The initial response to cardiac arrest is critical to saving lives. Each year, UK ambulance services respond to approximately 60,000 cases of suspected cardiac arrest. Resuscitation is attempted by ambulance services in less than half of these cases (approximately 28,000). The main reasons are that either the victim has been dead for several hours or has not received bystander CPR so by the time the emergency services arrive the person has died. Even when resuscitation is attempted, less than one in ten victims survive to go home from hospital. Strengthening the initial response to cardiac arrest by training and empowering more bystanders to perform CPR and by increasing the use of automated external defibrillators (AEDs) at least doubles the chances of survival and could save thousands of lives each year.

The Adult BLS Algorithm has been simplified further. For clarity, the algorithm is presented as a linear sequence of steps. It is recognised that the early steps of ensuring the scene is safe, checking for a response, opening the airway, checking for breathing and calling the ambulance may be accomplished simultaneously or in rapid succession.

Adult BLS Algorithm

The RCUK have however in the latest guidelines focused on improving outcomes for individuals in cardiac arrest and have therefore focused heavily on how outcomes can be improved.

The context they have given and what we should be emphasising on training is as follows:

  • All school children should be taught CPR and how to use an AED.
  • Everybody who is able should learn CPR
  • Availability of Defibrillators should be increased and they should be available in all places where large numbers of people and
  • where the likelihood of cardiac arrest is increased (Gym’s, sports facilities etc.)
  • Owners of AEDs should register their location and availability with local ambulance services
  • Be suspicious of cardiac arrest in any patient presenting with seizures and carefully assess whether the victim is breathing normally.
  • Emphasise Agonal Breathing as a sign of cardiac arrest
  • Start CPR and send for an AED as soon as possible.
  • If trained and able, combine chest compressions and rescue breaths, otherwise provide compression-only CPR.
  • If an AED arrives, switch it on and follow the instructions.
  • Minimise interruptions to CPR when attaching the AED pads to the victim.
  • Do not stop CPR unless you are certain the victim has recovered and is breathing normally or a health professional tells you to stop
  • Treat the victim who is choking by encouraging them to cough. If the victim deteriorates give up to 5 back slaps followed by up to 5 abdominal thrusts. If the victim becomes unconscious – start CPR.

Deliver compressions ‘in the centre of the chest’

Experimental studies show better haemodynamic responses when chest compressions are performed on the lower half of the sternum. Teach this location simply, such as, “place the heel of your hand in the centre of the chest with the other hand on top”. Accompany this instruction by a demonstration of placing the hands on the lower half of the sternum.

Chest compressions are most easily delivered by a single CPR provider kneeling by the side of the victim, as this facilitates movement between compressions and ventilations with minimal interruptions. Over-the-head CPR for single CPR providers and straddle-CPR for two CPR providers may be considered when it is not possible to perform compressions from the side, for example when the victim is in a confined space.

Compress the chest to a depth of 5–6 cm

Fear of doing harm, fatigue and limited muscle strength frequently result in CPR providers compressing the chest less deeply than recommended. Four observational studies, published after the 2010 Guidelines, suggest that a compression depth range of 4.5–5.5 cm in adults leads to better outcomes than all other compression depths during manual CPR. The Resuscitation Council (UK) endorses the ILCOR recommendation that it is reasonable to aim for a chest compression depth of approximately 5 cm but not more than 6 cm in the average sized adult. In making this recommendation, the Resuscitation Council (UK) recognises that it can be difficult to estimate chest compression depth and that compressions that are too shallow are more harmful than compressions that are too deep. Training should continue to prioritise achieving adequate compression depth.

Compress the chest at a rate of 100–120 per minute (min-1)

Two studies, with a total of 13,469 patients, found higher survival among patients who received chest compressions at a rate of 100–120 min-1. Very high chest compression rates were associated with declining chest compression depths. The Resuscitation Council (UK) therefore recommends that chest compressions are performed at a rate of 100–120 min-1.

Minimise pauses in chest compressions

Delivery of rescue breaths, defibrillation shocks, ventilations and rhythm analysis lead to pauses in chest compressions. Pre- and post-shock pauses of less than 10 seconds, and minimising interruptions in chest compressions (proportion of resuscitation attempt delivering chest compression >60% (chest compression fraction) are associated with improved outcomes. Pauses in chest compressions should be minimised and training should emphasise the importance of close co-operation between CPR providers to achieve this.

Chest recoil

Leaning on the chest preventing full chest wall recoil is common during CPR. Allowing complete recoil of the chest after each compression results in better venous return to the chest and may improve the effectiveness of CPR.CPR providers should, therefore, take care to avoid leaning forward after each chest compression.

CPR provider fatigue

Chest compression depth can decrease as soon as two minutes after starting chest compressions. If there are sufficient trained CPR providers, they should change over approximately every two minutes to prevent a decrease in compression quality. Changing CPR providers should not interrupt chest compressions.

Rescue breaths

CPR providers should give rescue breaths with an inflation duration of 1 second and provide sufficient volume to make the victim’s chest rise. Avoid rapid or forceful breaths. The maximum interruption in chest compression to give two breaths should not exceed 5 seconds.

Compression-only CPR

CPR providers trained and able to perform rescue breaths should perform chest compressions and rescue breaths as this may provide additional benefit for children and those who sustain an asphyxial cardiac arrest or where the EMS response interval is prolonged. Only if rescuers are unable to give rescue breaths should they do compression-only CPR.

The Resuscitation Council (UK) has carefully considered the balance between potential benefit and harm from compression-only CPR compared to standard CPR that includes ventilation. Our confidence in the equivalence between chest-compression-only and standard CPR is not sufficient to change current practice. The Resuscitation Council (UK), therefore, endorses the ILCOR and ERC recommendations that CPR providers should perform chest compressions for all patients in cardiac arrest. CPR providers trained and able to perform rescue breaths should perform chest compressions and rescue breaths as this may provide additional benefit for children and those who sustain an asphyxial cardiac arrest or where the EMS response interval is prolonged.

Resuscitation of children and victims of drowning

Many children do not receive resuscitation because potential CPR providers fear causing harm if they are not specifically trained in resuscitation for children. 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 are taught that the adult sequence may also be used for children who are not responsive and not breathing normally. 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.
  • If you are on your own, perform CPR for 1 minute before going for help.
  • Compress the chest by at least one third of its depth, approximately 4 cm for the infant and approximately 5 cm for an older child. Use two fingers for an infant under 1 year; use one or two hands as needed for a child over 1 year to achieve an adequate depth of compression.

The same modifications of 5 initial breaths and 1 minute of CPR by the lone CPR provider 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).

Teaching of Paediatric BLS in Doctors Surgeries

The RCUK has clarified the position in respect of teaching BLS. The Paediatric BLS protocol published by the RCUK for “healthcare professionals with a duty to respond” consists of a ratio of 15:2 compressions, to breaths. However this is designed for those who are regularly undertaking paediatric resuscitation. The RCUK has come up with a test consisting of 3 questions to assess whether someone should use the adult protocol or Paediatric protocol

  1. Are they healthcare professionals ?
  2. Are they expected to carry out resuscitation on infants and children as part of their day to day duties ?
  3. Do they work in teams ?

At the recent RCUK conference it was confirmed that Doctors and Nurses in GP practices should be taught to use the adult protocol (30:2) with the paediatric modifier of 5 initial rescue breathes.

Step by Step guidance on Basic Life Support

SEQUENCE

Technical description

SAFETY
Make sure you, the victim and any bystanders are safe
RESPONSE
Check the victim for a response
  • Gently shake his shoulders and ask loudly: “Are you all right?”
  • If he responds leave him in the position in which you find him, provided there is no further danger; try to find out what is wrong with him and get help if needed; reassess him regularly
AIRWAY
Open the airway
  • Turn the victim onto his back
  • Place your hand on his forehead and gently tilt his head back; with your fingertips under the point of the victim’s chin, lift the chin to open the airway
BREATHING
Look, listen and feel for normal breathing for no more than 10 seconds

In the first few minutes after cardiac arrest, a victim may be barely breathing, or taking infrequent, slow and noisy gasps. Do not confuse this with normal breathing. If you have any doubt whether breathing is normal, act as if it is they are not breathing normally and prepare to start CPR

DIAL 999
Call an ambulance (999)
  • Ask a helper to call if possible otherwise call them yourself
  • Stay with the victim when making the call if possible
  • Activate the speaker function on the phone to aid communication with the ambulance service
SEND FOR AED
Send someone to get an AED if available

If you are on your own, do not leave the victim, start CPR

CIRCULATION
Start chest compressions
  • Kneel by the side of the victim
  • Place the heel of one hand in the centre of the victim’s chest; (which is the lower half of the victim’s breastbone (sternum))
  • Place the heel of your other hand on top of the first hand
  • Interlock the fingers of your hands and ensure that pressure is not applied over the victim’s ribs
  • Keep your arms straight
  • Do not apply any pressure over the upper abdomen or the bottom end of the bony sternum (breastbone)
  • Position your shoulders vertically above the victim’s chest and press down on the sternum to a depth of 5–6 cm
  • After each compression, release all the pressure on the chest without losing contact between your hands and the sternum;
  • Repeat at a rate of 100–120 min-1
GIVE RESCUE BREATHS
After 30 compressions open the airway again using head tilt and chin lift and give 2 rescue breaths
  • Pinch the soft part of the nose closed, using the index finger and thumb of your hand on the forehead
  • Allow the mouth to open, but maintain chin lift
  • Take a normal breath and place your lips around his mouth, making sure that you have a good seal
  • Blow steadily into the mouth while watching for the chest to rise, taking about 1 second as in normal breathing; this is an effective rescue breath
  • Maintaining head tilt and chin lift, take your mouth away from the victim and watch for the chest to fall as air comes out
  • Take another normal breath and blow into the victim’s mouth once more to achieve a total of two effective rescue breaths. Do not interrupt compressions by more than 10 seconds to deliver two breaths. Then return your hands without delay to the correct position on the sternum and give a further 30 chest compressions

Continue with chest compressions and rescue breaths in a ratio of 30:2

If you are untrained or unable to do rescue breaths, give chest compression only CPR (i.e. continuous compressions at a rate of at least 100–120 min-1)

IF AN AED ARRIVES
Switch on the AED
  • Attach the electrode pads on the victim’s bare chest
  • If more than one rescuer is present, CPR should be continued while electrode pads are being attached to the chest
  • Follow the spoken/visual directions
  • Ensure that nobody is touching the victim while the AED is analysing the rhythm
If a shock is indicated, deliver shock
  • Ensure that nobody is touching the victim
  • Push shock button as directed (fully automatic AEDs will deliver the shock automatically)
  • Immediately restart CPR at a ratio of 30:2
  • Continue as directed by the voice/visual prompts

If no shock is indicated, continue CPR

  • Immediately resume CPR
  • Continue as directed by the voice/visual prompts
CONTINUE CPR

 

Do not interrupt resuscitation until:
  • A health professional tells you to stop
  • You become exhausted
  • The victim is definitely waking up, moving, opening eyes and breathing normally

It is rare for CPR alone to restart the heart. Unless you are certain the person has recovered continue CPR

RECOVERY POSITION

 

If you are certain the victim is breathing normally but is still unresponsive, place in the recovery position
  • Remove the victim’s glasses, if worn
  • Kneel beside the victim and make sure that both his legs are straight
  • Place the arm nearest to you out at right angles to his body, elbow bent with the hand palm-up
  • Bring the far arm across the chest, and hold the back of the hand against the victim’s cheek nearest to you
  • With your other hand, grasp the far leg just above the knee and pull it up, keeping the foot on the ground
  • Keeping his hand pressed against his cheek, pull on the far leg to roll the victim towards you on to his side
  • Adjust the upper leg so that both the hip and knee are bent at right angles
  • Tilt the head back to make sure that the airway remains open
  • If necessary, adjust the hand under the cheek to keep the head tilted and facing downwards to allow liquid material to drain from the mouth
  • Check breathing regularly

Be prepared to restart CPR immediately if the victim deteriorates or stops breathing normally

Information source The Resuscitation Council (UK) 2015 Guidelines

About Gary Hepburn

Gary Hepburn is Managing Director of Sirius Business Services Ltd who are approved suppliers of the Practice Index and offer, Basic Life Support, AED and Anaphylaxis, Fire Safety and Health & Safety consultancy and training to GP Practices, Dental Practices and Private Hospitals. Visit their page on The Practice Index. Gary is happy to discuss any issues, or concerns Practice Managers may have with existing providers, or to give advice on how the standard of training can be checked, email him at gary@SiriusBusinessServices.co.uk or Telephone 01305 769969