basic life 2. support Adult and automated external deﬁbrillation European Council Resuscitation Guidelines for Resuscitation 2015Section Resuscitation

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Resuscitation

j o ur na l h o me pa g e:ww w . e l s e v i e r . c o m / l o c a t e / r e s u s c i t a t i o n

European

Resuscitation

Council

Guidelines

for

Resuscitation

2015

Section

2. Adult

basic

life

support

and

automated

external

deﬁbrillation

Gavin

D. Perkins

a,b,∗

_,

_Anthony

_J.

_Handley

c

_,

_Rudolph

_W.

_Koster

d

_,

_Maaret

_Castrén

e

_,

Michael

A. Smyth

a,f

_,

_Theresa

_Olasveengen

g

_,

_Koenraad

_G.

_Monsieurs

h,i

_,

_Violetta

_Raffay

j

_,

Jan-Thorsten

Gräsner

k

_,

_Volker

_Wenzel

l

_,

_Giuseppe

_Ristagno

m

_,

_Jasmeet

_Soar

n

_,

_on

_behalf

_of

the

Adult

basic

life

support

and

automated

external

deﬁbrillation

section

Collaborators

1 a_Warwick_Medical_School,_University_of_Warwick,_Coventry,_UK

b_Critical_Care_Unit,_Heart_of_England_NHS_Foundation_Trust,_Birmingham,_UK c_Hadstock,_Cambridge,_UK

d_Department_of_Cardiology,_Academic_Medical_Center,_Amsterdam,_The_Netherlands

e_Department_of_Emergency_Medicine_and_Services,_Helsinki_University_Hospital_and_Helsinki_University,_Finland f_West_Midlands_Ambulance_Service_NHS_Foundation_Trust,_Dudley,_UK

g_Norwegian_National_Advisory_Unit_on_Prehospital_Emergency_Medicine_and_Department_of_{Anesthesiology,}_Oslo_University_Hospital,_Oslo,_Norway h_Faculty_of_Medicine_and_Health_Sciences,_University_of_Antwerp,_Antwerp,_Belgium

i_Faculty_of_Medicine_and_Health_Sciences,_University_of_Ghent,_Ghent,_Belgium j_Municipal_Institute_for_Emergency_Medicine_Novi_Sad,_Novi_Sad,_Serbia

k_Department_of_Anaesthesia_and_Intensive_Care_Medicine,_University_Medical_Center_{Schleswig-Holstein,}_Kiel,_Germany l_Department_of_{Anesthesiology}_and_Critical_Care_Medicine,_Medical_University_of_Innsbruck,_Innsbruck,_Austria m_Department_of_{Cardiovascular}_Research,_{IRCCS-Istituto}_di_Ricerche_{Farmacologiche}_“Mario_Negri”,_Milan,_Italy n_Anaesthesia_and_Intensive_Care_Medicine,_Southmead_Hospital,_Bristol,_UK

Introduction

Thischaptercontains guidanceonthetechniques used dur-ingtheinitialresuscitationofanadultcardiacarrestvictim.This includes basiclife support(BLS: airway, breathing and circula-tionsupportwithouttheuseofequipmentotherthanaprotective device)andtheuseofanautomatedexternaldeﬁbrillator(AED). Simpletechniquesusedin themanagement ofchoking (foreign bodyairwayobstruction)arealsoincluded.Guidelinesfortheuse ofmanualdeﬁbrillatorsandstartingin-hospitalresuscitationare foundinthesectionAdvancedLifeSupportChapter.1_A_summary

oftherecoverypositionisincluded,withfurtherinformation pro-videdintheFirstAidChapter.2

TheguidelinesarebasedontheILCOR2015Consensuson Sci-enceandTreatmentRecommendations(CoSTR)forBLS/AED.3_The

ILCORreviewfocusedon23keytopicsleadingto32treatment rec-ommendationsinthedomainsofearlyaccessandcardiacarrest prevention,early,high-qualityCPR, and earlydeﬁbrillation. For theseERCguidelinestheILCOR recommendationswere supple-mentedbyfocusedliteraturereviewsundertakenbyWritingGroup membersinareasnotreviewedbyILCOR.Thewritinggroupwere

∗ Correspondingauthor.

E-mailaddress:g.d.perkins@warwick.ac.uk(G.D.Perkins).

1 _The _members _of _the _Adult _basic _life _support _and _automated _external deﬁbrillationsectionCollaboratorsarelistedintheCollaboratorssection.

cognisantofthecostsandpotentialconfusioncreatedbychanging guidancefrom2010,andthereforesoughttolimitchangestothose judgedtobeessentialandsupportedbynewevidence.Guidelines weredraftedbyWritingGroupmembers,thenreviewedbythe fullwritinggroupandnationalresuscitationcouncilsbeforeﬁnal approvalbytheERCBoard.

SummaryofchangessincetheERC2010guidelines

Guidelines2015highlightsthecriticalimportanceofthe inter-actionsbetweentheemergencymedicaldispatcher,thebystander who provides CPR and the timely deployment of an auto-matedexternaldeﬁbrillator.Aneffective,co-ordinatedcommunity responsethatdrawstheseelementstogetheriskeytoimproving survivalfromout-of-hospitalcardiacarrest(Fig.2.1).

Theemergencymedicaldispatcherplaysanimportantrolein theearlydiagnosisofcardiacarrest,theprovisionof dispatcher-assistedCPR(alsoknownastelephoneCPR),andthelocationand dispatchof anautomated external deﬁbrillator. Thesooner the emergencyservicesarecalled,theearlierappropriatetreatment canbeinitiatedandsupported.

Theknowledge,skillsandconﬁdenceofbystanderswillvary accordingtothecircumstances,ofthearrest,leveloftrainingand priorexperience.

TheERCrecommendsthatthebystanderwhoistrainedandable shouldassessthecollapsedvictimrapidlytodetermineifthevictim

http://dx.doi.org/10.1016/j.resuscitation.2015.07.015

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COMMUNITY RESPONSE

SAVES LIVES 112

Fig.2.1.Theinteractionsbetweentheemergencymedicaldispatcher,thebystander whoprovidesCPRandthetimelyuseofanautomatedexternaldeﬁbrillatorarethe keyingredientsforimprovingsurvivalfromoutofhospitalcardiacarrest.

isunresponsiveandnotbreathingnormallyandthenimmediately alerttheemergencyservices.

Wheneverpossible,alerttheemergencyserviceswithout leav-ingthevictim.

Thevictimwhoisunresponsiveandnotbreathingnormallyis incardiacarrestandrequiresCPR.Immediatelyfollowingcardiac arrestbloodﬂowtothebrainisreducedtovirtuallyzero,whichmay causeseizure-likeepisodesthatmaybeconfusedwithepilepsy. Bystandersandemergencymedicaldispatchersshouldbe suspi-ciousofcardiacarrestinanypatientpresentingwithseizuresand carefullyassesswhetherthevictimisbreathingnormally.

Thewritinggroupendorses theILCORrecommendationthat allCPRprovidersshouldperformchestcompressionsforall vic-timsincardiacarrest.CPRproviderstrainedandabletoperform rescue breaths shouldcombine chest compressionsand rescue breaths.Theadditionofrescuebreathsmayprovideadditional ben-efitforchildren,forthosewhosustainanasphyxialcardiacarrest, orwhere theemergency medicalservice (EMS) response inter-valisprolonged.Ourconfidenceintheequivalencebetweenchest compression-onlyandstandardCPRisnotsufficienttochange cur-rentpractice.

Highqualitycardiopulmonaryresuscitationremainsessential toimprovingoutcomes.TheERC2015guidelineforchest compres-siondepthisthesameasthe2010guideline.CPRprovidersshould ensurechestcompressionsofadequatedepth(atleast5cmbutnot morethan6cm)witharateof100–120compressionsperminute. Allowthechesttorecoilcompletelyaftereachcompressionand minimiseinterruptionsincompressions.Whenprovidingrescue breaths/ventilationsspend approximately1sinﬂating thechest withsufﬁcientvolumetoensurethechestrisesvisibly.Theratioof chestcompressionstoventilationsremains30:2.Donotinterrupt chestcompressionsformorethan10stoprovideventilations.

Defibrillationwithin3–5minofcollapsecanproducesurvival ratesashighas50–70%.Earlydefibrillationcanbeachievedthrough CPRprovidersusingpublicaccessandon-siteAEDs.Publicaccess AEDprogrammesshouldbeactivelyimplementedinpublicplaces thathaveahighdensityofcitizens,suchasairports,railway sta-tions,bus terminals,sportfacilities,shoppingmalls,offices and casinos.It is herethat cardiacarrests are oftenwitnessed, and trainedCPR providerscan beon-scenequickly.Placing AEDsin areaswhere one cardiacarrest per5 years canbe expected is consideredcost-effective,andthecostperaddedlife-yearis com-parable to other medical interventions. Past experience of the numberofcardiacarrestsinacertainarea,aswellasthe neighbour-hoodcharacteristics,mayhelpguideAEDplacement.Registration

ofpublicaccessAEDsallowsdispatcherstodirectCPRprovidersto anearbyAEDandmayhelptooptimiseresponse.

TheadultCPRsequencecanbeusedsafelyinchildrenwhoare unresponsiveandnotbreathingnormally.ForCPRproviderswith additionaltrainingamodiﬁedsequencewhichincludesproviding5 initialrescuebreathsbeforestartingchestcompressionsand delay-inggoingforhelpintheunlikelysituationthattherescuerisalone isevenmoresuitableforthechildanddrowningvictim.Chest com-pressiondepthsinchildrenshouldbeatleastonethirdofthedepth ofthechest(forinfantsthatis4cm,forchildren5cm).

Aforeignbody causingsevereairway obstructionisa medi-calemergency.Italmostalwaysoccurswhilstthevictimiseating ordrinkingandrequiresprompttreatment.Startbyencouraging thevictimtocough.Ifthevictimhassevereairwayobstructionor beginstotire,givebackblowsand,ifthatfailstorelievethe obstruc-tion,abdominalthrusts.Ifthevictimbecomesunresponsive,start CPRimmediatelywhilsthelpissummoned.

Cardiacarrest

Sudden cardiac arrest (SCA) is one of theleading causesof deathinEurope.DependinghowSCAisdeﬁned,about55–113per 100,000inhabitantsayearor350,000–700,000individualsayear areaffectedinEurope.4–6_On_initial_heart-rhythm_analysis,_about

25–50%ofSCAvictimshaveventricularﬁbrillation(VF),a percent-agethathasdeclinedoverthelast20years.7–13_It_is_likely_that_many

morevictimshaveVForrapidventriculartachycardia(VT)atthe timeofcollapse,butbythetimetheﬁrstelectrocardiogram(ECG) isrecordedbyemergencymedicalservicepersonneltheirrhythm hasdeterioratedtoasystole.14,15_When_the_rhythm_is_recorded_soon

aftercollapse,inparticularbyanon-siteAED,theproportionof

vic-timsinVFcanbeashighas76%.16,17_More_victims_of_SCA_survive

ifbystandersactimmediatelywhileVFisstillpresent. Success-fulresuscitationislesslikelyoncetherhythmhasdeterioratedto asystole.

TherecommendedtreatmentforVFcardiacarrestis immedi-atebystanderCPRandearlyelectricaldeﬁbrillation.Mostcardiac arrests of non-cardiac origin have respiratory causes, such as drowning (among them many children) and asphyxia. Rescue breathsaswellaschestcompressionsarecriticalforsuccessful resuscitationofthesevictims.

Thechainofsurvival

TheChainofSurvivalsummarisesthevitallinksneededfor suc-cessfulresuscitation(Fig.2.2).Mostoftheselinksapplytovictims ofbothprimarycardiacandasphyxialarrest.18

Earlyrecognitionandcallforhelp

Chestpainshouldberecognisedasasymptomofmyocardial ischaemia.Cardiacarrestoccursinaquartertoathirdofpatients withmyocardialischaemiawithintheﬁrsthourafteronsetofchest pain.19_Recognising_the_cardiac_origin_of_chest_pain,_and_calling_the

emergencyservicesbeforeavictimcollapses,enablesthe emer-gencymedical servicetoarrivesooner,hopefully beforecardiac arresthasoccurred,thusleadingtobettersurvival.20–23

Once cardiac arrest has occurred, early recognition is criti-caltoenablerapid activationoftheEMSand promptinitiation of bystander CPR. The key observations are unresponsiveness

andnotbreathingnormally.Emergencymedicaldispatcherscan improverecognitionbyfocusingonthesekeywords.

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Fig.2.2.Thechainofsurvival.

EarlybystanderCPR

TheimmediateinitiationofCPRcandoubleorquadruple sur-vival from cardiac arrest.20,24–28 _If _able, _bystanders _with _CPR

trainingshouldgivechestcompressionstogetherwithventilations. Whenabystander hasnotbeentrained in CPR,theemergency medical dispatcher should instruct him or her to give chest-compression-onlyCPRwhileawaitingthearrivalofprofessional help.29–31

Earlydeﬁbrillation

Deﬁbrillationwithin3–5minofcollapsecanproducesurvival ratesashighas50–70%.Thiscanbeachievedbypublicaccessand onsiteAEDs.13,17,32,33_Each_minute_of_delay_to_{deﬁbrillation}_reduces

theprobabilityofsurvivaltodischargeby10–12%.Thelinksinthe chainworkbettertogether:whenbystanderCPRisprovided,the declineinsurvivalismoregradualandaverages3–4%perminute delaytodeﬁbrillation.20,24,34

Earlyadvancedlifesupportandstandardisedpost-resuscitation care

Advanced life support with airway management, drugs and correctingcausalfactorsmaybeneededifinitialattemptsat resus-citation are un-successful. The quality of treatmentduring the post-resuscitationphaseaffectsoutcomeandareaddressedinthe adultadvancedlifesupportandpostresuscitationcarechapters.1,35

Thecriticalneedforbystanderstoact

In most communities, the median time from emergency callto emergency medical service arrival (responseinterval) is

5–8min,16,36–38_or_8–11_min_to_a_ﬁrst_shock.13,27_During_this_time

thevictim’ssurvivaldependsonbystanderswhoinitiateCPRand useanautomatedexternaldeﬁbrillator(AED).

Victimsof cardiacarrest needimmediateCPR. Thisprovides a small but critical blood flow to the heart and brain. It also increasesthelikelihood that theheartwill resumeaneffective rhythmand pumpingpower.Chestcompressionsare especially importantifashockcannotbedeliveredwithinthefirstfew min-utesaftercollapse.39_After_{defibrillation,}_if_the_heart_is_still_viable,

itspacemakeractivityresumesandproducesanorganisedrhythm followedbymechanicalcontraction.Intheﬁrstminutesafter ter-minationofVF,theheartrhythmmaybeslow,andtheforceof contractionsweak;chestcompressionsmust becontinueduntil adequatecardiacfunctionreturns.

UseofanAEDbylayCPRprovidersincreasessurvivalfrom car-diacarrestinpublicplaces.16_AED_use_in_residential_areas_is_also

increasing.40_An_AED_uses_voice_prompts_to_guide_the_CPR_provider,

analysethecardiacrhythmandinstructtheCPRprovidertodeliver ashockifVForrapidventriculartachycardia(VT)isdetected.They areaccurateandwilldeliverashockonlywhenVF(orrapidVT)is present.41,42

Recognitionofcardiacarrest

Recognisingcardiacarrestcanbechallenging.Bothbystanders and emergency call handlers (emergency medical dispatchers) havetodiagnosecardiacarrestpromptlyinordertoactivatethe chainofsurvival.Checkingthecarotidpulse(oranyotherpulse) hasprovedtobeaninaccuratemethodforconﬁrmingthepresence orabsenceofcirculation.43–47

Agonalbreathsareslowanddeepbreaths,frequentlywitha characteristicsnoringsound.Theyoriginatefromthebrainstem, thepartofthebrainthatremainsfunctioningforsomeminutes evenwhendeprivedofoxygen.Thepresenceofagonalbreathing canbeerroneouslyinterpretedasevidencethatthereisa circu-lationand CPRisnotneeded.Agonalbreathingmaybepresent inupto40%ofvictimsintheﬁrstminutesaftercardiacarrest, andifrespondedtoasasignofcardiacarrest,isassociatedwith highersurvivalrates.48_The_{signiﬁcance}_of_agonal_breathing_should

beemphasisedduringbasiclifesupporttraining.49,50_Bystanders

shouldsuspectcardiacarrestandstartCPRifthevictimis unre-sponsiveandnotbreathingnormally.

Immediatelyfollowingcardiacarrest,bloodﬂowtothebrainis reducedtovirtuallyzero,whichmaycauseseizure-likeepisodes thatcanbeconfusedwithepilepsy.Bystandersshouldbe suspi-ciousofcardiacarrestinanypatientpresentingwithseizures.51,52

Although bystanderswho have witnessedcardiac arrest events reportchangesinthevictims’skincolour,notablypallorandbluish changesassociatedwithcyanosis,thesechangesarenotdiagnostic ofcardiacarrest.51

Roleoftheemergencymedicaldispatcher

Theemergencymedicaldispatcherplaysacriticalroleinthe diagnosisofcardiacarrest,theprovisionofdispatcherassistedCPR (alsoknownastelephoneCPR),thelocationanddispatchofan auto-matedexternal deﬁbrillatoranddispatchofa highpriorityEMS response.Thesoonertheemergencyservicesarecalled,theearlier appropriatetreatmentcanbeinitiatedandsupported.

Dispatcherrecognitionofcardiacarrest

Conﬁrmation of cardiac arrest, at the earliest opportunity is critical. If the dispatcher recognises cardiac arrest, survival is more likely becauseappropriate measures canbe taken.53,54

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Enhancingdispatcherabilitytoidentifycardiacarrest,and optimis-ingemergencymedicaldispatcherprocesses,maybecost-effective solutionstoimproveoutcomesfromcardiacarrest.

Useofscripteddispatchprotocolswithinemergencymedical communicationcentres,includingspeciﬁcquestionstoimprove cardiac arrest recognition may be helpful. Patients who are

unresponsiveandnotbreathingnormallyshouldbepresumedto beincardiacarrest.Adherencetosuchprotocolsmayhelpimprove cardiacarrestrecognition,9,55–57_whereas_failure_to_adhere_to

pro-tocolsreducesratesofcardiacarrestrecognitionbydispatchersas wellastheprovisionoftelephone-CPR.58–60

Obtaining an accurate description of the victim’s breathing patternischallengingfor dispatchers.Agonalbreathing isoften present, and callers may mistakenly believe the victim is still breathingnormally.9,60–68_Offering_dispatchers_additional

educa-tion,specificallyaddressingtheidentificationandsignificanceof agonalbreathing,canimprovecardiacarrestrecognition,increase theprovision of telephone-CPR,67,68 _and _reduce_the _number _of

missedcardiacarrestcases.64

Askingquestionsregardingtheregularityorpatternof breath-ingmayhelpimproverecognitionofabnormalbreathingandthus identiﬁcationofcardiacarrest.Iftheinitialemergencycallisfora personsufferingseizures,thecalltakershouldbehighlysuspicious ofcardiacarrest,evenifthecallerreportsthatthevictimhasaprior historyofepilepsy.61,69

DispatcherassistedCPR

BystanderCPRratesarelowinmanycommunities. Dispatcher-assistedCPR(telephone-CPR)instructionshavebeendemonstrated to improve bystander CPR rates,9,56,70–72 _reduce _the _time _to

ﬁrstCPR,56,57,68,72,73_increase_the_number_of_chest_compressions

delivered70 _and _improve _patient _outcomes _following

out-of-hospitalcardiacarrest(OHCA)inallpatientgroups.9,29–31,57,71,74

Dispatchersshouldprovidetelephone-CPRinstructions inall casesofsuspectedcardiacarrestunlessatrainedproviderisalready deliveringCPR.Whereinstructionsarerequiredforanadultvictim, dispatchersshouldprovidechest-compression-onlyCPR instruc-tions.

Ifthevictimisa child,dispatchersshouldinstructcallersto provide both ventilations and chest compressions. Dispatchers shouldthereforebetrainedtoprovideinstructionsforboth tech-niques.

AdultBLSsequence

Thesequenceofstepsfortheinitialassessmentandtreatmentof theunresponsivevictimaresummarisedinFig.2.3.Thesequence ofstepstakesthereaderthroughrecognitionofcardiacarrest, call-ingEMS,startingCPRandusinganAED.Thenumberofstepshas beenreducedtofocusonthekeyactions.Theintentoftherevised algorithmistopresentthestepsinalogicalandconcisemanner thatiseasyforalltypesofrescuerstolearn,rememberandperform.

Fig.2.4 presents the detailed step-by-step sequence for the trainedprovider.Itcontinuestohighlighttheimportanceof ensur-ingrescuer,victimandbystandersafety.Callingforadditionalhelp (ifrequired)isincorporatedinthealertingemergencyservicesstep below.Forclaritythealgorithmispresentedasalinearsequence ofsteps.Itisrecognisedthattheearlystepsofcheckingresponse, openingtheairway,checkingforbreathingandcallingthe emer-gencymedicaldispatchermaybeaccomplishedsimultaneouslyor inrapidsuccession.

Those who are not trained to recognise cardiac arrest and startCPRwouldnotbeawareoftheseguidelinesandtherefore requiredispatcherassistancewhenever theymakethedecision

Unresponsive and

not breathing normally

Call Emergency Services

Give 30 chest compressions

Give 2 rescue breaths

Continue CPR 30:2

As soon as AED arrives - switch

it on and follow instructions

Fig.2.3.TheBLS/AEDAlgorithm.

to call 112. These guidelines do not therefore include speciﬁc recommendationsforthosewhoarenottrainedtorecognise car-diacarrestandstartCPR.

Theremainderofthissectionprovidessupplemental informa-tiononsomeofthekeystepswithintheoverallsequence. Openingtheairwayandcheckingforbreathing

Thetrainedprovidershouldassessthecollapsedvictimrapidly todetermineiftheyareresponsiveandbreathingnormally.

Opentheairwayusingtheheadtiltandchinlifttechniquewhilst assessingwhetherthepersonisbreathingnormally.Donotdelay assessmentbycheckingfor obstructionsintheairway.Thejaw thrustandﬁngersweeparenolongerrecommendedforthelay provider.Checkfor breathingusingthetechniquesdescribedin

Fig.2.4notingthecriticalimportanceofrecognisingagonal breath-ingdescribedabove.

Alertingemergencyservices

112istheEuropeanemergencyphonenumber,available every-where in theEU,free of charge. It ispossible tocall112from ﬁxedand mobilephonestocontact anyemergency service:an ambulance,theﬁrebrigadeorthepolice.SomeEuropeancountries provideanalternativedirectaccessnumbertoemergencymedical services,whichmaysavetime.Bystandersshouldthereforefollow nationalguidelinesontheoptimalphonenumbertouse.

Earlycontactwiththeemergencyserviceswillfacilitate dis-patcherassistanceintherecognitionofcardiacarrest,telephone instructiononhowtoperformCPR,emergencymedicalservice/ﬁrst responderdispatch,andonlocatinganddispatchingofanAED.75–78

Ifpossible,stay withthevictimwhilecallingtheemergency services.Ifthephonehasaspeakerfacilityswitchittospeakeras thiswillfacilitatecontinuousdialoguewiththedispatcher includ-ing(ifrequired)CPRinstructions.79_It_seems_reasonable_that_CPR

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Fig.2.4.(Continued).

trainingshouldincludehowtoactivatethespeakerphone.80

Addi-tionalbystandersmaybeusedtohelpcalltheemergencyservices. Startingchestcompressions

InadultsneedingCPR,thereisahighprobabilityofaprimary cardiaccause.Whenbloodﬂowstopsaftercardiacarrest,theblood in thelungs and arterial systemremains oxygenatedfor some minutes.Toemphasisethepriorityofchestcompressions,itis rec-ommendedthatCPRshouldstartwithchestcompressionsrather thaninitialventilations.Manikinstudiesindicatethatthisis asso-ciatedwithashortertimetocommencementofCPR.81–84

Whenprovidingmanualchestcompressions: 1.Delivercompressions‘inthecentreofthechest’.

2.Compresstoadepthofatleast5cmbutnotmorethan6cm. 3.Compressthechestatarateof100–120min−1withasfew

inter-ruptionsaspossible.

4.Allowthechesttorecoilcompletelyaftereachcompression;do notleanonthechest.

Handposition

Experimental studies show better haemodynamic responses whenchestcompressionsareperformedonthelowerhalfofthe sternum.85–87_It_is_recommended_that_this_location_be_taught_in_a

simpliﬁedway,suchas,“placetheheelofyourhandinthecentre ofthechestwiththeotherhandontop”.Thisinstructionshouldbe accompaniedbyademonstrationofplacingthehandsonthelower halfofthesternum.88,89

ChestcompressionsaremosteasilydeliveredbyasingleCPR provider kneeling by the side of the victim, as this facilitates movementbetweencompressionsandventilationswithminimal interruptions. Over-the-head CPR for single CPR providers and

straddle-CPRfortwoCPRprovidersmaybeconsideredwhenitis notpossibletoperformcompressionsfromtheside,forexample whenthevictimisinaconﬁnedspace.90,91

Compressiondepth

Fearof doingharm, fatigueand limitedmusclestrength fre-quentlyresultinCPRproviderscompressingthechestlessdeeply than recommended.Four observational studies,publishedafter the2010Guidelines,suggestthatacompressiondepthrangeof 4.5–5.5cminadultsleadstobetteroutcomesthanallother com-pressiondepthsduringmanualCPR.92–95_Based_on_an_analysis_of

9136patients,compressiondepthsbetween40and55mmwith apeak at46mm,wereassociatedwithhighestsurvivalrates.94

Thereisalsoevidencefrom oneobservationalstudysuggesting thatacompressiondepthofmorethan6cmisassociatedwithan increasedrateofinjuryinadultswhencomparedwithcompression depthsof5–6cmduringmanualCPR.96_The_ERC_endorses_the_ILCOR

recommendationthatitisreasonabletoaimforachest compres-sionofapproximately5cmbutnotmorethan6cmintheaverage sizedadult.Inmakingthis recommendationtheERCrecognises thatitcanbedifﬁculttoestimatechestcompressiondepthandthat compressionsthataretooshallowaremoreharmfulthan compres-sionsthataretoodeep.TheERCthereforedecidedtoretainthe2010 guidancethatchestcompressionsshouldbeatleast5cmbutnot morethan6cm.Trainingshouldcontinuetoprioritiseachieving adequatecompressiondepth.

Compressionrate

Chestcompressionrateisdeﬁnedastheactualrateof compres-sionsbeinggivenatanyonetime.Itdiffersfromthenumberofchest compressionsinaspeciﬁctimeperiod,whichtakesintoaccount anyinterruptionsinchestcompressions.

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rate of 100–120min , compared to >140, 120–139, <80 and 80–99min−1.Veryhighchestcompressionrateswereassociated with declining chest compression depths.97,98 _The _ERC

recom-mends,therefore,thatchest compressionsshouldbeperformed atarateof100–120min−1.

Minimisingpausesinchestcompressions

Delivery of rescue breaths, shocks, ventilations and rhythm analysisleadtopausesinchestcompressions.Pre-andpost-shock pausesoflessthan10s,andchestcompressionfractions>60%are associatedwithimprovedoutcomes.99–103 _Pauses_in_chest

com-pressionsshouldbeminimised,byensuringCPRproviderswork effectivelytogether.

Firmsurface

CPRshouldbeperformedonafirmsurfacewheneverpossible. Air-filledmattressesshouldberoutinelydeflatedduringCPR.104

Theevidencefortheuseofbackboardsisequivocal.105–109_If_a

back-boardisused,takecaretoavoidinterruptingCPRanddislodging intravenouslinesorothertubesduringboardplacement.

Chestwallrecoil

Leaningonthechestpreventingfullchestwallrecoiliscommon duringCPR.110,111_Allowing_complete_recoil_of_the_chest_after_each

compressionresultsinbettervenousreturntothechestandmay improvetheeffectivenessofCPR.110,112–114_CPR_providers_should,

therefore,takecaretoavoidleaningaftereachchestcompression.

Dutycycle

Optimaldutycycle(ratioofthetimethechestiscompressed tothe total time from one compression tothe next) hasbeen studiedinanimalmodelsandsimulationstudieswithinconsistent results.115–123_A_recent_human_{observational}_study_has_challenged

thepreviouslyrecommendeddutycycleof 50:50bysuggesting compressionphases>40%mightnotbefeasible,andmaybe associ-atedwithdecreasedcompressiondepth.124_For_CPR_providers,_the

dutycycleisdifﬁculttoadjust,andislargelyinﬂuencedbyother chestcompressionparameters.119,124_In_reviewing _the_evidence,

theERCacknowledgesthereisverylittleevidencetorecommend anyspeciﬁcdutycycleand,therefore,insufﬁcientnewevidenceto promptachangefromthecurrentlyrecommendedratioof50%.

Feedbackoncompressiontechnique

TheuseofCPRfeedbackandpromptdevicesduringCPRin clin-icalpractice is intended toimprove CPRquality as a meansof increasingthechancesofROSCandsurvival.125,126_The_forms_of

feedbackincludevoiceprompts,metronomes,visualdials, numer-icaldisplays,waveforms,verbalprompts,andvisualalarms.

TheeffectofCPRfeedbackorpromptdeviceshasbeenstudied intworandomisedtrials92,127_and₁₁_{observational}_studies.128–138

Noneofthesestudiesdemonstratedimprovedsurvivaltodischarge withfeedback,andonlyonefoundasigniﬁcantlyhigherROSCrate inpatientswherefeedbackwasused.However,inthisstudy feed-backwasactivatedatthediscretionofthephysicianandnodetails ofthedecision-makingprocesstoactivateornotactivatefeedback wereprovided.136_The_use_of_CPR_feedback_or_prompt_devices

dur-ingCPRshouldonlybeconsideredaspartofabroadersystemof carethatshouldincludecomprehensiveCPRqualityimprovement initiatives,138,139_rather_than_as_an_isolated_{intervention.}

Innon-paralysed,gaspingpigswithunprotected,unobstructed airways,continuous-chest-compressionCPRwithoutartiﬁcial ven-tilationresultedinimprovedoutcome.140_Gasping_may_be_present

earlyaftertheonsetofcardiacarrestinaboutonethirdofhumans, thusfacilitatinggasexchange.48_During_CPR_in_intubated_humans,

however,themediantidalvolumeperchestcompressionwasonly about40mL,insufﬁcientforadequateventilation.141_In_witnessed

cardiacarrestwithventricularﬁbrillation,immediatecontinuous chest compressions tripledsurvival.142 _Accordingly, _continuous

chest compressions maybe most beneﬁcial in the early, ‘elec-tric’and‘circulatory’phasesofCPR,whileadditionalventilation becomesmoreimportantinthelater,‘metabolic’phase.39

DuringCPR,systemic bloodﬂow,andthusblood ﬂowtothe lungs,issubstantiallyreduced,solowertidalvolumesand respi-ratoryratesthannormalcanmaintaineffectiveoxygenationand ventilation.143–146 _When_the_airway _is _unprotected,_a _tidal

vol-ume of 1L produces significantly more gastric inflation than a tidal volume of 500mL.147 _Inflation _durations _of ₁_s_are

feasi-blewithoutcausingexcessivegastricinsufﬂation.148_Inadvertent

hyperventilationduringCPRmayoccurfrequently,especiallywhen usingmanualbag-valve-maskventilationin aprotectedairway. While this increasedintrathoracic pressure149 _and _peak _airway

pressure,150_a_carefully_controlled_animal_experiment_revealed_no

adverseeffects.151

FromtheavailableevidencewesuggestthatduringadultCPR tidal volumes of approximately 500–600mL (6–7mLkg−1) are delivered.Practically,thisisthevolumerequiredtocausethechest torisevisibly.152_CPR_providers_should_aim_for_an_inﬂation

dura-tionofabout1s,withenoughvolumetomakethevictim’schest rise,butavoidrapidorforcefulbreaths.Themaximum interrup-tioninchestcompressiontogivetwobreathsshouldnotexceed 10s.153_These_{recommendations}_apply_to_all_forms_of_ventilation

duringCPRwhentheairwayisunprotected,including mouth-to-mouthandbag-maskventilation,withandwithoutsupplementary oxygen.

Mouth-to-noseventilation

Mouth-to-nose ventilation is an acceptable alternative to mouth-to-mouthventilation.154_It_may_be_considered_if_the_victim’s

mouthisseriouslyinjuredorcannotbeopened,theCPRprovideris assistingavictiminthewater,oramouth-to-mouthsealisdifﬁcult toachieve.

Mouth-to-tracheostomyventilation

Mouth-to-tracheostomyventilationmaybeusedforavictim withatracheostomytubeortrachealstomawhorequiresrescue breathing.155

Compression–ventilationratio

Animaldatasupporta ratioofcompressiontoventilationof greaterthan15:2.156–158 _A_mathematical_model _suggests_that_a

ratioof30:2providesthebestcompromise betweenbloodﬂow andoxygendelivery.159,160_A_ratio_of_30:2_was_recommended_in

Guidelines2005and2010forthesingleCPRproviderattempting resuscitationofanadult.Thisdecreasedthenumberof interrup-tionsincompressionandtheno-ﬂowfraction,161,162_and_reduced

the likelihood of hyperventilation.149,163 _Several _{observational}

studieshavereportedslightlyimprovedoutcomesafter implemen-tationoftheguidelinechanges,whichincludedswitchingfroma compressionventilationratioof15:2–30:2.161,162,164,165 _The_ERC

continues,therefore,torecommendacompressiontoventilation ratioof30:2.

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Compression-onlyCPR

Animalstudieshaveshownthatchest-compression-onlyCPR maybeaseffectiveascombinedventilationandcompressionin theﬁrstfewminutesafternon-asphyxialarrest.140,166_Animal_and

mathematicalmodelstudiesofchest-compression-onlyCPRhave alsoshownthatarterialoxygenstoresdepletein2–4min.158,167_If

theairwayisopen,occasionalgaspsandpassivechestrecoilmay providesomeairexchange.48,141,168–170

Observationalstudies,classiﬁedmostlyasverylow-quality evi-dence,havesuggestedequivalenceofchest-compression-onlyCPR andchestcompressionscombinedwithrescuebreathsinadults withasuspectedcardiaccausefortheircardiacarrest.26,171–182

TheERChascarefullyconsideredthebalancebetween poten-tialbenefitand harmfrom compression-only CPRcompared to standardCPRthatincludesventilation.Ourconfidenceinthe equiv-alencebetweenchest-compression-onlyandstandardCPRisnot sufficienttochangecurrentpractice.TheERC,therefore,endorses theILCORrecommendations that allCPR providersshould per-formchest compressionsfor all patientsin cardiac arrest. CPR providerstrainedandabletoperformrescuebreathsshould per-formchestcompressionsandrescuebreathsasthismayprovide additionalbenefitforchildrenandthosewhosustainan asphyx-ialcardiacarrest175,183,184_or_where_the_EMS_response_interval_is

prolonged.179

Useofanautomatedexternaldeﬁbrillator

AEDs are safe and effective when used by laypeople with minimalornotraining.185 _AEDs_make _it_possible_to_{deﬁbrillate}

many minutes before professional help arrives. CPR providers shouldcontinueCPRwithminimalinterruptionofchest compres-sionswhile attachinganAED andduringitsuse. CPRproviders shouldconcentrateonfollowingthevoicepromptsimmediately when they are spoken, in particular resuming CPR as soon as instructed, and minimizing interruptions in chest compression. Indeed,pre-shockandpost-shockpausesinchestcompressions shouldbeasshortaspossible.99,100,103,186_Standard_AEDs_are

suit-ableforuseinchildrenolderthan8years.187–189

Forchildrenbetween1and8yearspaediatricpadsshouldbe used,togetherwithanattenuatororapaediatricmodeifavailable; ifthesearenotavailable,theAEDshouldbeusedasitis.Thereare afewcasereportsofsuccessfuluseofAEDSinchildrenagesless than1year.190,191_The_incidence_of_shockable_rhythms_in_infants

isverylowexceptwhenthereiscardiacdisease.187–189,192–195_In

theserarecases,ifanAEDistheonlydeﬁbrillatoravailable,itsuse shouldbeconsidered(preferablywithadoseattenuator). CPRbeforedeﬁbrillation

Theimportanceof immediatedefibrillationhasalwaysbeen emphasisedinguidelinesandduringteaching,andisconsidered tohavea majorimpactonsurvivalfromventricularfibrillation. Thisconceptwaschallengedin2005becauseevidencesuggested thataperiodofupto180sofchestcompressionbefore defibrilla-tionmightimprovesurvivalwhentheEMSresponsetimeexceeded

4–5min.196,197_Three_more_recent_trials_have_not_conﬁrmed_this

survivalbeneﬁt.198–200 _An_analysis_of_one_randomised _trial

sug-gestedadeclineinsurvivaltohospitaldischargebyaprolonged periodofCPR(180s)anddelayeddeﬁbrillationinpatientswith ashockableinitialrhythm.200 _Yet,_for_EMS_agencies_with_higher

baselinesurvival-to-hospitaldischargerates(definedas>20%for aninitialshockablerhythm),180sofCPRpriortodefibrillationwas morebeneficialcomparedtoashorterperiodofCPR(30–60s).201

The ERC recommends that CPR should be continued while a

deﬁbrillatororAEDisbeingbroughton-siteandapplied,but deﬁ-brillationshouldnotbedelayedanylonger.

Intervalbetweenrhythmchecks

The2015ILCORConsensusonSciencereportedthatthereare currentlynostudies that directlyaddress thequestionof opti-malintervalsbetweenrhythmchecks,andtheireffectonsurvival: ROSC;favourableneurologicalorfunctionaloutcome;survivalto discharge;coronaryperfusionpressureorcardiacoutput.

InaccordancewiththeILCORrecommendation,andfor consis-tencywithpreviousguidelines,theERCrecommendsthatchest compressionsshouldbepausedeverytwominutestoassessthe cardiacrhythm.

Voiceprompts

ItiscriticallyimportantthatCPRproviderspayattentiontoAED voicepromptsandfollowthemwithoutanydelay.Voiceprompts areusuallyprogrammable,anditisrecommendedthattheybeset inaccordancewiththesequenceofshocksandtimings forCPR givenabove.Theseshouldincludeatleast:

1.minimisepausesinchestcompressionsforrhythmanalysisand charging;

2.asingleshockonly,whenashockablerhythmisdetected; 3.avoicepromptforimmediateresumptionofchestcompression

aftertheshockdelivery;

4.aperiod of2minofCPRbeforethenextvoicepromptto re-analysetherhythm.

DevicesmeasuringCPRqualitymayinadditionprovide real-timeCPRfeedbackandsupplementalvoice/visualprompts.

The duration of CPR between shocks, as well as the shock sequenceandenergylevelsarediscussedfurtherintheAdvanced LifeSupportChapter.1

Inpractice,AEDsareusedmostlybytrainedrescuers,where thedefaultsettingofAEDpromptsshouldbeforacompressionto ventilationratioof30:2.

If(inanexception)AEDsare placedina settingwhere such trainedrescuersareunlikelytobeavailableorpresent,theowner ordistributormaychoosetochangethesettingstocompression only.

Fully-automaticAEDs

Havingdetectedashockablerhythm,afullyautomaticAEDwill deliverashockwithoutfurtheractionfromtheCPRprovider.One manikinstudyshowedthatuntrainednursingstudentscommitted fewersafetyerrorsusingafullyautomaticAEDcomparedwitha semi-automaticAED.202_A_simulated_cardiac_arrest_scenario_on_a

manikinshowedthatsafetywasnotcompromisedwhenuntrained layCPRprovidersusedafullyautomaticAEDratherthana semi-automaticAED.203_There_are_no_human_data_to_determine_whether

theseﬁndingscanbeappliedtoclinicaluse. Publicaccessdeﬁbrillation(PAD)programmes

Theconditionsforsuccessfulresuscitationinresidentialareas arelessfavourablethaninpublicareas:fewerwitnessedarrests, lowerbystanderCPR ratesand,asa consequence,fewer shock-ablerhythmsthaninpublicplaces.Thislimitstheeffectiveness ofAED usefor victimsathome.204 _Most_studies_{demonstrating}

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able,victimswere deﬁbrillatedmuch sooner and witha better chanceof survival.16,209 _However, _an_AED _delivered_a _shock _in

only 3.7%209 _or _1.2%16 _of _all _cardiac _arrests._There _was_a _clear

inverserelationshipintheJapanesestudybetweenthenumber ofAEDsavailable persquare km andthe intervalbetween col-lapseandtheﬁrstshock,leadingtoapositiverelationshipwith survival.

PublicaccessAEDprogrammesshould,therefore,beactively implementedinpublicplaceswithahighdensityandmovement ofcitizenssuchasairports,railwaystations,busterminals,sport facilities,shoppingmalls,ofﬁcesandcasinoswherecardiacarrests areusuallywitnessedand trainedCPRproviderscanquicklybe onscene. Thedensity and location of AEDsrequired for a suf-ﬁcientlyrapid responseisnotwellestablished,especially when cost-effectivenessisaconsideration.Factorssuchasexpected inci-dence of cardiac arrest, expected number of life-years gained, andreduction inresponsetime ofAED-equippedCPR providers comparedtothatoftraditionalEMSshouldinformthisdecision. PlacementofAEDsinareaswhereonecardiacarrestper5years canbeexpectedis consideredcost-effectiveand comparableto othermedicalinterventions.210–212_For_residential_areas,_past

expe-rience may help guide AED placement, as may neighbourhood characteristics.213,214_Registration_of_AEDs_for_public_access,_so_that

dispatcherscandirect CPRproviderstoanearbyAED,mayalso helptooptimiseresponse.215_Cost_saving_is_also_possible,_as_early

deﬁbrillationand on-siteAEDdeﬁbrillationmayresultinlower in-hospitalcost.216,217

ThefullpotentialofAEDshasnotyetbeenachieved,because theyare mostly used in public settings, yet60–80% of cardiac arrestsoccurathome.TheproportionofpatientsfoundinVFis lowerathomethaninpublicplaces,howevertheabsolute num-berofpotentiallytreatablepatientsishigherathome.204 _Public

accessdeﬁbrillation(PAD)rarelyreachesvictimsathome.208

Dif-ferentstrategies,therefore,arerequiredforearlydefibrillationin residentialareas.Dispatchedfirstresponders,suchaspoliceand firefighterswill,ingeneral,havelongerresponsetimes,butthey havethepotentialtoreachthewholepopulation.17,36_The_logistic

problemforﬁrstresponderprogrammesisthattheCPRprovider needstoarrive,not justearlier thanthetraditionalambulance, butwithin5–6minoftheinitialcall,toenableattempted deﬁ-brillationintheelectricalorcirculatoryphaseofcardiacarrest.39

With longerdelays, the survival beneﬁt decreases: a few min-utes gain intime will haveless impact whena ﬁrst responder arrivesmorethan10minafterthecall.34,218 _Dispatched_lay_CPR

providers, local to the victim and directed to a nearby AED, mayimprovebystanderCPRrates33_and_help_reduce_the_time_to

deﬁbrillation.40

WhenimplementinganAEDprogramme,communityand pro-gramme leaders should consider factors such as development of a team with responsibility for monitoring, maintaining the devices,trainingandretrainingindividualswhoarelikelytouse theAED,andidentiﬁcationofagroupofvolunteerindividualswho arecommittedtousingtheAEDforvictimsofcardiacarrest.219

Fundsmust beallocatedona permanent basisto maintainthe programme.

ProgrammesthatmakeAEDsavailableinresidentialareashave onlybeenevaluatedforresponsetime,notforsurvivalbeneﬁt.40

Theacquisition ofan AEDfor individual useathome,even for those considered at high risk of sudden cardiac arrest is not effective.220

Thespecialcircumstanceschapterprovidestheevidence under-pinningtheERCrecommendationthatAEDsshouldbemandatory onboardallcommercialaircraftinEurope,includingregionaland low-costcarriers.221

simple and clearsignageindicating thelocation ofan AEDand the fastest way to it is important. ILCOR has designed such an AED sign that may be recognised worldwide and this is recommended.222

In-hospitaluseofAEDs

Therearenopublishedrandomisedtrialscomparingin-hospital useofAEDswithmanualdefibrillators.Twoolder,observational studiesof adultswithin-hospital cardiacarrestfrom shockable rhythmsshowedhighersurvival-to-hospitaldischargerateswhen defibrillationwasprovidedthroughanAEDprogrammethanwith manual defibrillation alone.223,224 _A _more _recent _{observational}

studyshowedthatanAEDcouldbeusedsuccessfullybeforethe arrivalofthehospitalresuscitationteam.225 _Three_{observational}

studiesshowednoimprovementsinsurvivaltohospitaldischarge for in-hospital adult cardiac arrest when using an AED com-paredwithmanualdeﬁbrillation.226–228_In_one_of_these_studies,226

patientsintheAEDgroupwithnon-shockablerhythmshadalower survival-to-hospital discharge rate compared withthose in the manualdeﬁbrillatorgroup(15%vs.23%;P=0.04).Anotherlarge observational study of 11,695patients from 204hospitals also showed that in-hospital AED use was associated with a lower survival-to-dischargeratecomparedwithnoAEDuse(16.3%vs. 19.3%;adjustedrateratio[RR],0.85;95%conﬁdenceinterval[CI], 0.78–0.92;P<0.001).229_For_{non-shockable}_rhythms,_AED_use_was

associatedwithlowersurvival(10.4%vs.15.4%;adjustedRR,0.74; 95%CI,0.65–0.83;P<0.001),andasimilarsurvivalratefor shock-ablerhythms,(38.4%vs.39.8%;adjustedRR,1.00;95%CI,0.88–1.13; P=0.99).This suggeststhat AEDs maycause harmful delays in starting CPR,orinterruptions inchest compressionsin patients with non-shockable rhythms.230 _Only _a _small _proportion _(less

than20%)ofin-hospitalcardiacarrestshaveaninitialshockable rhythm.229,231,232

WerecommendtheuseofAEDsinthoseareasofthehospital wherethereisariskofdelayeddeﬁbrillation,233 _because_it _will

takeseveralminutesforaresuscitationteamtoarrive,andfirst respondersdonothaveskillsinmanualdefibrillation.Thegoalis toattemptdefibrillationwithin3minofcollapse.Inhospitalareas wherethereisrapidaccesstomanualdefibrillation,eitherfrom trainedstafforaresuscitationteam,manualdefibrillationshould beusedinpreferencetoanAED.Whicheverdefibrillationtechnique ischosen(andsomehospitalsmaychoosetohavedefibrillators thatofferbothanAEDandmanualmode)aneffectivesystemfor trainingandretrainingshouldbeinplace.232,234_Sufficient

health-careprovidersshouldbetrainedtoenablethegoalofproviding theﬁrstshockwithin3minofcollapseanywhereinthehospital. Hospitalsshouldmonitorcollapse-to-ﬁrstshockintervalsandaudit resuscitationoutcomes.

RiskstotheCPRproviderandrecipientsofCPR

RiskstothevictimwhoreceivesCPRwhoisnotincardiacarrest ManyCPRprovidersdonotinitiateCPRbecausetheyare con-cernedthatdeliveringchestcompressionstoavictimwhoisnotin cardiacarrestwillcauseseriouscomplications.Threestudieshave investigatedtheriskofCPRinpersonsnotincardiacarrest.235–237

Pooleddatafromthesethreestudies,encompassing345patients, foundanincidenceofbonefracture(ribsandclavicle)of1.7%(95% CI0.4–3.1%),painintheareaofchestcompression8.7%(95%CI 5.7–11.7%),andnoclinicallyrelevantvisceralinjury.BystanderCPR extremelyrarelyleadstoseriousharminvictimswhoare even-tuallyfoundnottobeincardiacarrest.CPRprovidersshouldnot,

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therefore,bereluctanttoinitiateCPRbecauseofconcernofcausing harm.

RiskstothevictimwhoreceivesCPRwhoisincardiacarrest Asystematicreviewofskeletalinjuriesaftermanualchest com-pressionreportsanincidenceofribfracturesrangingfrom13%to 97%,andofsternalfracturesfrom1%to43%.238 _Visceral_injuries

(lung,heart,abdominalorgans)occurlessfrequentlyandmayor maynotbeassociatedwithskeletalinjury.239_Injuries_are_more

commonwhenthedepthofchestcompressionexceeds6cminthe averageadult.96

RiskstotheCPRproviderduringtrainingandduringreal-lifeCPR ObservationalstudiesoftrainingoractualCPRperformanceand casereportshavedescribedrareoccurrencesofmusclestrain,back symptoms,shortnessofbreath,hyperventilation,pneumothorax, chestpain,myocardialinfarctionandnerveinjury.240,241_The

inci-denceof theseeventsis verylow, and CPR trainingand actual performanceissafeinmostcircumstances.242_Individuals

under-takingCPRtrainingshouldbeadvisedofthenatureandextentofthe physicalactivityrequiredduringthetrainingprogramme.Learners andCPRproviderswhodevelopsigniﬁcantsymptoms(e.g.chest painorsevereshortnessofbreath)duringCPRtrainingshouldbe advisedtostop.

CPRproviderfatigue

Severalmanikin studies have foundthat chest compression depthcandecrease assoonastwo minutesafterstarting chest compressions.243_An_in-hospital_patient_study_showed_that,_even

whileusingreal-time feedback,themeandepthofcompression deterioratedbetween1.5and3minafterstartingCPR.244_It_is

there-forerecommendedthatCPRproviderschangeoverabouteverytwo minutestopreventadecreaseincompressionqualityduetoCPR providerfatigue.ChangingCPRprovidersshouldnotinterruptchest compressions.

Risksduringdeﬁbrillation

ManystudiesofpublicaccessdeﬁbrillationshowedthatAEDs canbeused safelyby laypeopleand ﬁrstresponders.185 _A

sys-tematic review identiﬁed eight papers that reported a total of 29 adverse events associated with deﬁbrillation.245 _The _causes

includedaccidentalorintentionaldefibrillatormisuse,device mal-functionandaccidentaldischargeduringtrainingormaintenance procedures. Four single-case reports described shocks to CPR providersfromdischargingimplantablecardioverterdefibrillators (ICDs),inonecaseresultinginaperipheralnerveinjury.No stud-ieswereidentified whichreportedharmtoCPRprovidersfrom attemptingdefibrillationinwetenvironments.

AlthoughinjurytotheCPRproviderfromadeﬁbrillatorshock isextremelyrare,ithasbeenshownthatstandardsurgicalgloves donotprovideadequateprotection.246–249_CPR_providers,

there-fore,shouldnotcontinuemanualchestcompressionsduringshock delivery,andvictimsshouldnotbetouchedduringICDdischarge. DirectcontactbetweentheCPRproviderandthevictimshouldbe avoidedwhendeﬁbrillationisperformed.

Psychologicaleffects

One large, prospective trial of public access deﬁbrillation reportedfewadversepsychologicaleffectsassociatedwithCPRor AEDusethat requiredintervention.242 _Two_large, _{retrospective,}

questionnaire-basedstudiesfoundthatbystanderswhoperformed CPR regarded theirintervention as a positive experience.250,251

Family members witnessing a resuscitation attempt may also derivepsychologicalbeneﬁt.252–254_The_rare_occurrences_of_adverse

psychologicaleffectsinCPRprovidersafterperformingCPRshould berecognisedandmanagedappropriately.

Diseasetransmission

TheriskofdiseasetransmissionduringtrainingandactualCPR performanceisextremelylow.255–257_Wearing_gloves_during_CPR

isreasonable,butCPRshouldnotbedelayedorwithheldifgloves arenotavailable.

Barrierdevicesforusewithrescuebreaths

Threestudiesshowedthatbarrierdevicesdecrease transmis-sionofbacteriaduringrescuebreathingincontrolledlaboratory settings.258,259 _No _studies _were _identiﬁed _which _examined_the

safety,effectivenessorfeasibilityofusingbarrierdevices(suchas afaceshieldorfacemask)topreventvictimcontactwhen per-formingCPR.Neverthelessifthevictimisknowntohaveaserious infection(e.g.HIV,tuberculosis,hepatitisBorSARS)abarrierdevice isrecommended.

Ifabarrierdeviceisused,careshouldbetakentoavoid unneces-saryinterruptionsinCPR.Manikinstudiesindicatethatthequality ofCPRissuperiorwhenapocketmaskisusedcomparedtoa bag-valvemaskorsimplefaceshield.260–262

Foreignbodyairwayobstruction(choking)

Foreign body airway obstruction (FBAO) is an uncommon but potentially treatable cause of accidental death.263 _As_most

chokingeventsareassociatedwitheating,theyarecommonly wit-nessed. Asvictims initiallyare consciousand responsive,there areoftenopportunitiesforearlyinterventionswhichcanbelife saving.

Recognition

Becauserecognitionofairwayobstructionisthekeyto success-fuloutcome,itisimportantnottoconfusethisemergencywith fainting,myocardialinfarction,seizureorotherconditionsthatmay causesuddenrespiratorydistress,cyanosisorlossofconsciousness. FBAOusuallyoccurswhilethevictimiseatingordrinking. Peo-pleatincreasedriskofFBAOincludethosewithreducedconscious levels,drugand/oralcoholintoxication,neurologicalimpairment withreducedswallowingandcoughreﬂexes(e.g.stroke, Parkin-son’sdisease),respiratorydisease,mentalimpairment,dementia, poordentitionandolderage.264

Fig.2.5 presentsthetreatmentalgorithm for theadult with FBAO. Foreign bodies may cause either mild or severe airway obstruction.Itisimportanttoasktheconsciousvictim“Areyou choking?”Thevictimthatisabletospeak,coughandbreathehas mildobstruction.Thevictimthatisunabletospeak,hasa weak-eningcough,isstrugglingorunabletobreathe,hassevereairway obstruction.

Treatmentformildairwayobstruction

Coughinggenerateshighandsustainedairwaypressuresand mayexpeltheforeignbody.Aggressivetreatmentwithbackblows, abdominalthrustsandchestcompressions,maycauseharmand canworsentheairwayobstruction.Thesetreatmentsshouldbe reservedforvictimswhohavesignsofsevereairwayobstruction. Victimswithmildairwayobstructionshouldremainunder contin-uousobservationuntiltheyimprove,assevereairwayobstruction maysubsequentlydevelop.

Treatmentforsevereairwayobstruction

Theclinicaldataonchokingarelargelyretrospectiveand anec-dotal. For conscious adults and children over one year of age

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Fig.2.5.(Continued).

withcompleteFBAO,casereports havedemonstratedthe effec-tiveness of back blows or ‘slaps’, abdominal thrusts and chest thrusts.265 _{Approximately}_50%_of_episodes_of_airway_obstruction

arenotrelievedbyasingletechnique.266 _The_likelihood_of

suc-cessisincreasedwhencombinationsofbackblowsorslaps,and abdominalandchestthrustsareused.265

Treatmentofforeignbodyairwayobstructioninanunresponsive victim

Arandomisedtrialincadavers267 _and _two_prospective

stud-iesinanaesthetisedvolunteers268,269_showed_that_higher_airway

pressurescan begenerated using chest thrusts compared with abdominalthrusts.Bystanderinitiationofchestcompressionfor unresponsiveorunconsciousvictimsofFBAOwasindependently associatedwithgoodneurologicaloutcome(oddsratio,10.57;95% CI,2.472–65.059,P<0.0001).270_Chest_compressions_should,

there-fore,bestartedpromptlyifthevictimbecomesunresponsiveor unconscious.After30compressionsattempt2rescuebreaths,and continueCPRuntilthevictimrecoversandstartstobreathe nor-mally.

Aftercareandreferralformedicalreview

FollowingsuccessfultreatmentofFBAO,foreignmaterialmay neverthelessremain in the upper or lower airways and cause complications later. Victims with a persistent cough, difﬁculty swallowingorthesensationofanobjectbeingstillstuckinthe throatshould,therefore,bereferredforamedicalopinion. Abdom-inalthrustsandchestcompressionscanpotentiallycauseserious internalinjuries and all victimssuccessfully treated withthese measuresshouldbeexaminedafterwardsforinjury.

Resuscitationofchildren(seealsoRecognitionofCardiac Arrestsection)andvictimsofdrowning(seealsoTheChain ofSurvivalsection)

Manychildrendonotreceiveresuscitationbecausepotential CPRprovidersfearcausingharmiftheyarenotspeciﬁcallytrained inresuscitationforchildren.Thisfearisunfounded:itisfarbetter tousetheadultBLSsequenceforresuscitationofachildthanto donothing.Foreaseofteachingandretention,laypeopleshould betaughtthattheadultsequencemayalsobeusedforchildren whoarenotresponsiveandnotbreathingnormally.Thefollowing minormodiﬁcationstotheadultsequencewillmakeitevenmore suitableforuseinchildren:

• Give5initialrescuebreathsbeforestartingchestcompressions. • GiveCPRfor1minbeforegoingforhelpintheunlikelyeventthe

CPRproviderisalone.

• Compressthechestbyatleastonethirdofitsdepth;use2ﬁngers foraninfantunderoneyear;use1or2handsforachildover1 yearasneededtoachieveanadequatedepthofcompression.

Thesamemodificationsof5initialbreathsand1minofCPRby theloneCPRproviderbeforegettinghelp,mayimproveoutcome forvictimsofdrowning.Thismodificationshouldbetaughtonly tothosewhohaveaspecificdutyofcaretopotentialdrowning victims(e.g.lifeguards).

Collaborators

LeoL.Bossaert,UniversityofAntwerp,Antwerp,Belgium,

AntonioCaballero,EmergencyDepartment,HospitalUniversitario VirgendelRocío,Sevilla,Spain,

PascalCassan,GlobalFirstAidReferenceCentre,International Fed-erationofRedCrossandRedCrescent,Paris,France,

CristinaGranja,EmergencyandIntensiveCareDepartment, Hospi-taldeFaro,CentroHospitalardoAlgarve,Porto,Portugal,

Claudio Sandroni, Department of Anaesthesiologyand Intensive Care,CatholicUniversitySchoolofMedicine,Rome,Italy,

DavidA.Zideman,ImperialCollegeHealthcareNHSTrust,London, UK,

Jerry P. Nolan, Department of Anaesthesia and Intensive Care Medicine,RoyalUnitedHospital,Bath,UK,

IanMaconochie, PaediatricEmergency Medicine and NIHR BRC, ImperialCollege,London,UK,

RobertGreif,Department ofAnaesthesiologyandPainMedicine, UniversityHospitalBernandUniversityBern,Bern,Switzerland.

Conﬂictsofinterest

GavinD.Perkins EditorResuscitation JasmeetSoar EditorResuscitation

AnthonyJ.Handley MedicaladvisorBA,Virgin,Placesfor people,LifesavingSocieties,Trading CompanySecretaryRCUK

GiuseppeRistagno ExpertadviceZOLL:ECGinterpretation MaaretCastren MedicaladvisoryBoardFalckFoundation RudolphW.Koster MedicaladvisorPhysioControland

HeartSine,ResearchgrantsPhysioControl, Philips,Zoll,CardiacScience,Deﬁbtech, Jolife

VolkerWenzel Researchgrants,Medicaladvisor,Speakers honorarium“AOPOrphan”Pharma Jan-ThorstenGräsner Noconflictofinterestreported KoenraadG.Monsieurs Noconflictofinterestreported MichaelA.Smyth Noconflictofinterestreported TheresaMarieroOlasveengen Noconflictofinterestreported ViolettaRaffay Noconflictofinterestreported

(15)

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