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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
1.
Executive
summary
Koenraad
G.
Monsieurs
a,b,∗,
Jerry
P.
Nolan
c,d,
Leo
L.
Bossaert
e,
Robert
Greif
f,g,
Ian
K.
Maconochie
h,
Nikolaos
I.
Nikolaou
i,
Gavin
D.
Perkins
j,p,
Jasmeet
Soar
k,
Anatolij
Truhláˇr
l,m,
Jonathan
Wyllie
n,
David
A.
Zideman
o,
on
behalf
of
the
ERC
Guidelines
2015
Writing
Group
1aEmergencyMedicine,FacultyofMedicineandHealthSciences,UniversityofAntwerp,Antwerp,Belgium bFacultyofMedicineandHealthSciences,UniversityofGhent,Ghent,Belgium
cAnaesthesiaandIntensiveCareMedicine,RoyalUnitedHospital,Bath,UK dSchoolofClinicalSciences,UniversityofBristol,Bristol,UK
eUniversityofAntwerp,Antwerp,Belgium
fDepartmentofAnaesthesiologyandPainMedicine,UniversityHospitalBern,Bern,Switzerland gUniversityofBern,Bern,Switzerland
hPaediatricEmergencyMedicineDepartment,ImperialCollegeHealthcareNHSTrustandBRCImperialNIHR,ImperialCollege,London,UK iCardiologyDepartment,KonstantopouleioGeneralHospital,Athens,Greece
jWarwickMedicalSchool,UniversityofWarwick,Coventry,UK
kAnaesthesiaandIntensiveCareMedicine,SouthmeadHospital,Bristol,UK
lEmergencyMedicalServicesoftheHradecKrálovéRegion,HradecKrálové,CzechRepublic
mDepartmentofAnaesthesiologyandIntensiveCareMedicine,UniversityHospitalHradecKrálové,HradecKrálové,CzechRepublic nDepartmentofNeonatology,TheJamesCookUniversityHospital,Middlesbrough,UK
oImperialCollegeHealthcareNHSTrust,London,UK pHeartofEnglandNHSFoundationTrust,Birmingham,UK
Introduction
Thisexecutivesummaryprovidestheessentialtreatment algo-rithmsfortheresuscitationofchildrenandadultsandhighlights themainguidelinechangessince2010.Detailedguidanceis pro-videdineachofthetensections,whicharepublishedasindividual paperswithinthisissueofResuscitation.ThesectionsoftheERC Guidelines2015are:
1.Executivesummary
2.Adultbasiclifesupportandautomatedexternaldefibrillation1 3.Adultadvancedlifesupport2
4.Cardiacarrestinspecialcircumstances3 5.Post-resuscitationcare4
6.Paediatriclifesupport5
7.Resuscitationandsupportoftransitionofbabiesatbirth6 8.Initialmanagementofacutecoronarysyndromes7 9.Firstaid8
10.Principlesofeducationinresuscitation9
11.Theethicsofresuscitationandend-of-lifedecisions10
∗ Correspondingauthor.
E-mailaddress:koen.monsieurs@uza.be(K.G.Monsieurs). 1 SeeAppendix1fortheERC2015GuidelinesWritingGroup.
TheERCGuidelines2015thatfollowdonotdefinetheonlyway thatresuscitationcanbedelivered;theymerelyrepresentawidely acceptedview ofhow resuscitationshouldbeundertaken both safelyandeffectively.Thepublicationofnewand revised treat-mentrecommendationsdoesnotimplythatcurrentclinicalcareis eitherunsafeorineffective.
Summaryofthechangessincethe2010Guidelines
Adultbasiclifesupportandautomatedexternaldefibrillation • The ERC Guidelines 2015highlight thecritical importance of
theinteractionsbetweentheemergencymedicaldispatcher,the bystanderwhoprovidesCPRandthetimelydeploymentofan AED.Aneffective,co-ordinatedcommunityresponsethatdraws theseelementstogetheriskeytoimprovingsurvivalfrom out-of-hospitalcardiacarrest(Fig.1.1).
• Theemergencymedical dispatcherplaysanimportant rolein theearlydiagnosisofcardiacarrest,theprovisionof dispatcher-assistedCPR(alsoknownastelephoneCPR),andthelocationand dispatchofanAED.
• Thebystanderwhoistrainedandableshouldassessthecollapsed victimrapidlytodetermineifthevictimisunresponsiveandnot breathingnormallyandthenimmediatelyalerttheemergency services.
http://dx.doi.org/10.1016/j.resuscitation.2015.07.038
COMMUNITY RESPONSE
SAVES LIVES 112
Fig.1.1.Theinteractionsbetweentheemergencymedicaldispatcher,thebystander whoprovidesCPRandthetimelyuseofanautomatedexternaldefibrillatorarethe keyingredientsforimprovingsurvivalfromoutofhospitalcardiacarrest.
• Thevictimwhoisunresponsiveandnotbreathingnormallyis incardiacarrestandrequiresCPR.Bystandersand emergency medical dispatchersshould besuspicious of cardiac arrest in anypatientpresentingwithseizuresandshouldcarefullyassess whetherthevictimisbreathingnormally.
• CPRprovidersshouldperformchestcompressionsforallvictims incardiacarrest.CPRproviderstrainedandabletoperformrescue breathsshouldcombinechestcompressionsandrescuebreaths. Ourconfidenceintheequivalencebetweenchest compression-onlyandstandardCPRisnotsufficienttochangecurrentpractice. • High-qualityCPRremainsessentialtoimprovingoutcomes.The guidelinesoncompressiondepthandratehavenotchanged.CPR providersshouldensurechestcompressionsofadequatedepth (atleast5cmbutnomorethan6cm)witharateof100–120 com-pressionsmin−1.Aftereachcompressionallowthechesttorecoil completelyandminimiseinterruptionsincompressions.When providingrescuebreaths/ventilations spendapproximately1s inflatingthechestwithsufficientvolumetoensurethechestrises visibly.Theratioofchestcompressionstoventilationsremains 30:2.Donotinterruptchestcompressionsformorethan10sto provideventilations.
• Defibrillationwithin3–5minof collapsecanproducesurvival rates as highas 50–70%. Early defibrillationcan be achieved throughCPRprovidersusingpublicaccessandon-siteAEDs. Pub-licaccessAEDprogrammesshouldbeactivelyimplementedin publicplacesthathaveahighdensityofcitizens.
• TheadultCPRsequencecanbeusedsafelyinchildrenwhoare unresponsiveand not breathing normally. Chestcompression depthsinchildrenshouldbeatleastonethirdofthedepthof thechest(forinfantsthatis4cm,forchildren5cm).
• Aforeignbodycausingsevereairwayobstructionisa medical emergencyandrequiresprompttreatmentwithbackblowsand, ifthatfailstorelievetheobstruction,abdominalthrusts.Ifthe victimbecomesunresponsiveCPRshouldbestartedimmediately whilsthelpissummoned.
Adultadvancedlifesupport
TheERC 2015ALSGuidelines emphasiseimprovedcare and implementation of the guidelines in order to improve patient focusedoutcomes.11Thekeychangessince2010are:
• Continuedemphasisontheuseofrapidresponsesystemsforcare ofthedeterioratingpatientandpreventionofin-hospitalcardiac arrest.
• Continuedemphasisonminimallyinterruptedhigh-qualitychest compressionsthroughoutanyALSintervention:chest compres-sionsarepausedbrieflyonlytoenablespecificinterventions.This includesminimisinginterruptionsinchestcompressionsforless than5stoattemptdefibrillation.
• Keepingthefocusontheuseofself-adhesivepadsfor defibrilla-tionandadefibrillationstrategytominimisethepreshockpause, althoughwerecognisethatdefibrillatorpaddlesareusedinsome settings.
• There is a new section on monitoring during ALS with an increasedemphasisontheuseofwaveformcapnographyto con-firmandcontinuallymonitortrachealtubeplacement,qualityof CPRandtoprovideanearlyindicationofreturnofspontaneous circulation(ROSC).
• Thereareavarietyofapproachestoairwaymanagementduring CPRandastepwiseapproachbasedonpatientfactorsandthe skillsoftherescuerisrecommended.
• The recommendations for drugtherapy during CPR have not changed,butthereisgreaterequipoise concerningtheroleof drugsinimprovingoutcomesfromcardiacarrest.
• The routine use of mechanical chest compression devices is not recommended, but they are a reasonable alternative in situationswheresustainedhigh-qualitymanualchest compres-sionsareimpracticalorcompromiseprovidersafety.
• Peri-arrestultrasoundmayhavearoleinidentifyingreversible causesofcardiacarrest.
• Extracorporeallifesupporttechniquesmayhavearoleasarescue therapyinselectedpatientswherestandardALSmeasuresarenot successful.
Cardiacarrestinspecialcircumstances Specialcauses
This section has been structured to cover the potentially reversible causes of cardiac arrest that must be identified or excludedduringanyresuscitation.Theyaredividedintotwogroups offour–4Hsand4Ts:hypoxia;hypo-/hyperkalaemiaandother electrolytedisorders;hypo-/hyperthermia;hypovolaemia;tension pneumothorax;tamponade(cardiac);thrombosis(coronaryand pulmonary);toxins(poisoning).
• Survivalafteranasphyxia-inducedcardiacarrestisrareand sur-vivorsusuallyhavesevereneurologicalimpairment.DuringCPR, earlyeffectiveventilationofthelungswithsupplementary oxy-genisessential.
• Ahighdegreeofclinicalsuspicionandaggressivetreatmentcan preventcardiacarrestfromelectrolyteabnormalities.Thenew algorithmprovidesclinicalguidancetoemergencytreatmentof life-threateninghyperkalaemia.
• Hypothermicpatientswithout signsof cardiac instabilitycan berewarmed externallyusing minimallyinvasive techniques. Patientswithsignsofcardiacinstabilityshouldbetransferred directlytoacentrecapableofextracorporeallifesupport(ECLS). • Earlyrecognitionandimmediatetreatmentwithintramuscular adrenalineremains the mainstayof emergency treatmentfor anaphylaxis.
• A new treatment algorithm for traumatic cardiac arrest was developedtoprioritisethesequenceoflife-savingmeasures. • Transport withcontinuing CPR may be beneficial in selected
patientswherethereisimmediatehospitalaccesstothe catheter-isation laboratory and experience in percutaneous coronary intervention(PCI)withongoingCPR.
• Recommendationsforadministrationoffibrinolyticswhen pul-monaryembolismisthesuspectedcauseofcardiacarrestremain unchanged.
Specialenvironments
Thespecial environmentssectionincludesrecommendations forthetreatmentofcardiacarrestoccurringinspecificlocations. Theselocationsarespecialisedhealthcarefacilities(e.g.operating theatre,cardiacsurgery,catheterisationlaboratory,dialysisunit, dentalsurgery),commercialairplanesorairambulances,fieldof play,outsideenvironment(e.g.drowning,difficultterrain,high alti-tude,avalancheburial,lightningstrikeandelectricalinjuries)orthe sceneofamasscasualtyincident.
• Anewsectioncoversthecommoncausesandrelevant modifica-tiontoresuscitativeproceduresinpatientsundergoingsurgery. • In patientsfollowing major cardiacsurgery, keytosuccessful
resuscitationisrecognisingtheneedtoperformimmediate emer-gencyresternotomy,especiallyinthecontextoftamponadeor haemorrhage,whereexternalchestcompressionsmaybe inef-fective.
• Cardiacarrestfromshockablerhythms(ventricularfibrillation (VF) or pulseless ventricular tachycardia (pVT)) during car-diaccatheterisationshouldimmediatelybetreatedwithupto threestackedshocksbeforestartingchestcompressions.Useof mechanicalchestcompressiondevicesduringangiographyis rec-ommendedtoensurehigh-qualitychest compressionsandto reducetheradiationburden topersonnelduring angiography withongoingCPR.
• AEDsandappropriateCPRequipmentshouldbemandatoryon boardofallcommercialaircraftinEurope,includingregionaland low-costcarriers.Consideranover-the-headtechniqueofCPRif restrictedaccessprecludesaconventionalmethod.
• Suddenandunexpectedcollapseofanathleteonthefieldofplay islikelytobecardiacinoriginandrequiresrapidrecognitionand earlydefibrillation.
• Submersionexceeding10minisassociatedwithpooroutcome. Bystandersplayacriticalroleinearlyrescueandresuscitation. Resuscitationstrategiesforthoseinrespiratoryorcardiacarrest continuetoprioritiseoxygenationandventilation.
• The chances of good outcome from cardiac arrest in diffi-cultterrainormountainsmaybereducedbecauseofdelayed accessand prolongedtransport. Thereis a recognised role of airrescueandavailabilityofAEDsinremotebutoften-visited locations.
• The cut-off criteria for prolonged CPR and extracorporeal rewarmingofavalanchevictimsincardiacarresthavebecome morestringenttoreducethenumberoffutilecasestreatedwith extracorporeallifesupport(ECLS).
• SafetymeasuresareemphasisedwhenprovidingCPRtothe vic-timofanelectricalinjury.
• Duringmasscasualtyincidents(MCIs),ifthenumber of casu-altiesoverwhelmshealthcareresources,withholdCPRforthose withoutsignsoflife.
Specialpatients
ThesectiononspecialpatientsgivesguidanceforCPRinpatients withseverecomorbidities(asthma,heartfailurewithventricular assistdevices,neurologicaldisease,obesity)andthosewithspecific physiologicalconditions(pregnancy,elderlypeople).
• Inpatientswithventricularassistdevices(VADs),confirmation ofcardiacarrestmaybedifficult.Ifduringthefirst10daysafter surgery,cardiacarrestdoesnotrespondtodefibrillation,perform resternotomyimmediately.
• PatientswithsubarachnoidhaemorrhagemayhaveECGchanges thatsuggestanacutecoronarysyndrome(ACS).Whethera com-putedtomography(CT)brainscanisdonebeforeoraftercoronary angiographywilldependonclinicaljudgement.
• Nochangestothesequenceofactionsarerecommendedin resus-citationofobesepatients,butdeliveryofeffectiveCPRmaybe challenging.Consider changingrescuersmorefrequentlythan thestandard2-mininterval.Earlytrachealintubationis recom-mended.
• Forthepregnantwomanincardiacarrest,high-qualityCPRwith manualuterinedisplacement,earlyALSanddeliveryofthefoetus ifearlyreturnofspontaneouscirculation(ROSC)isnotachieved remainkeyinterventions.
Post-resuscitationcare
ThissectionisnewtotheEuropeanResuscitationCouncil Guide-lines;in2010thetopicwasincorporatedintothesectiononALS.12 TheERChascollaboratedwiththeEuropeanSocietyofIntensive CareMedicinetoproducethesepost-resuscitationcareguidelines, whichrecognisetheimportanceofhigh-qualitypost-resuscitation careasavitallinkintheChainofSurvival.13
Themostimportant changesin post-resuscitationcaresince 2010include:
• There is a greater emphasis on the need for urgent coro-nary catheterisation and percutaneous coronary intervention (PCI)following out-of-hospital cardiacarrest of likely cardiac cause.
• Targetedtemperaturemanagementremainsimportantbutthere is now an option totarget a temperature of 36◦C insteadof thepreviouslyrecommended32–34◦C.Thepreventionoffever remainsveryimportant.
• Prognosticationisnowundertakenusingamultimodalstrategy andthereisemphasisonallowingsufficienttimeforneurological recoveryandtoenablesedativestobecleared.
• Anovelsectionhasbeenaddedwhichaddressesrehabilitation aftersurvivalfromacardiacarrest.Recommendationsincludethe systematicorganisationoffollow-upcare,whichshouldinclude screeningforpotentialcognitiveandemotionalimpairmentsand provisionofinformation.
Paediatriclifesupport
Guidelinechangeshavebeenmadeinresponsetoconvincing newscientificevidenceand,byusingclinical,organisationaland educationalfindings,theyhavebeenadaptedtopromotetheiruse andeaseforteaching.
Basiclifesupport
• Thedurationofdeliveringabreathisabout1s,tocoincidewith adultpractice.
• Forchestcompressions,thelowersternumshouldbedepressed byatleastonethirdtheanterior-posteriordiameterofthechest (4cmfortheinfantand5cmforthechild).
Managingtheseriouslyillchild
• Iftherearenosignsofsepticshock,thenchildrenwithafebrile illnessshouldreceivefluidwithcautionandreassessment follow-ingitsadministration.Insomeformsofsepticshock,restricting fluidswithisotoniccrystalloidmaybeofbenefitascomparedto liberaluseoffluids.
• Forcardioversionofasupraventriculartachycardia(SVT),the ini-tialdosehasbeenrevisedto1Jkg-1.
Paediatriccardiacarrestalgorithm
• Manyofthefeaturesarecommonwithadultpractice. Post-resuscitationcare
• Preventfeverinchildrenwhohavereturnofspontaneous circu-lation(ROSC)fromanout-of-hospitalsetting.
• Targetedtemperaturemanagementofchildrenpost-ROSCshould beeithernormothermiaormildhypothermia.
• Thereisnosinglepredictorforwhentostopresuscitation. Resuscitationandsupportoftransitionofbabiesatbirth
Thefollowingarethemainchangesthathavebeenmadetothe ERCguidelinesforresuscitationatbirthin2015:
• Supportoftransition:Recognisingtheuniquesituationofthe babyatbirth,whorarelyrequiresresuscitationbutsometimes needsmedicalhelpduringtheprocessofpostnataltransition. Thetermsupportoftransitionhasbeenintroducedtobetter dis-tinguishbetweeninterventionsthatareneededtorestorevital organfunctions(resuscitation)ortosupporttransition.
• Cord clamping: For uncompromised babies, a delay in cord clampingof at least1min fromthecomplete deliveryof the infant,isnowrecommended fortermandpretermbabies.As yetthereisinsufficientevidencetorecommendanappropriate timeforclampingthecordinbabieswhorequireresuscitationat birth.
• Temperature:Thetemperatureofnewlybornnon-asphyxiated infantsshouldbemaintainedbetween36.5◦Cand37.5◦Cafter birth.Theimportanceofachievingthishasbeenhighlightedand reinforcedbecauseofthestrongassociationwithmortalityand morbidity.Theadmissiontemperatureshouldberecordedasa predictorofoutcomeaswellasaqualityindicator.
• Maintenanceoftemperature:At<32weeksgestation,a combi-nationofinterventionsmayberequiredinadditiontomaintain the temperature between 36.5◦C and 37.5◦C after delivery throughadmissionandstabilisation.Thesemayincludewarmed humidifiedrespiratorygases,increasedroomtemperatureplus plasticwrappingofbodyandhead,plusthermalmattressora thermalmattressalone,allofwhichhavebeeneffectivein reduc-inghypothermia.
• Optimalassessment of heart rate: It is suggested in babies requiringresuscitationthattheECGcanbeusedtoprovidearapid andaccurateestimationofheartrate.
• Meconium:Trachealintubation shouldnot be routinein the presenceofmeconium andshouldonlybeperformedfor sus-pectedtrachealobstruction.Theemphasisshouldbeoninitiating ventilationwithinthefirst minuteof lifein non-breathingor ineffectivelybreathinginfantsandthisshouldnotbedelayed. • Air/oxygen:Ventilatorysupportofterminfantsshouldstartwith
air.Forpreterminfants,eitherairoralowconcentrationof oxy-gen(up to30%) should beused initially. If, despite effective ventilation,oxygenation(ideallyguidedby oximetry)remains unacceptable,useofahigherconcentrationofoxygenshouldbe considered.
• CPAP: Initial respiratory support of spontaneously breathing preterminfantswithrespiratory distressmaybeprovided by CPAPratherthanintubation.
Acutecoronarysyndromes
Thefollowingisasummaryofthemostimportantnewviews andchangesinrecommendationsforthediagnosisandtreatment ofacutecoronarysyndromes(ACS).
DiagnosticInterventionsinACS
• Pre-hospitalrecordingofa12-leadelectrocardiogram(ECG) is recommendedinpatientswithsuspectedSTsegmentelevation acutemyocardialinfarction(STEMI).ForthosewithSTEMIthis expeditespre-hospitalandin-hospitalreperfusionandreduces mortality.
• Non-physicianECGSTEMIinterpretationwithorwithouttheaid ofcomputerECGSTEMIinterpretationissuggestedifadequate diagnostic performance can be maintained through carefully monitoredqualityassuranceprogrammes.
• Pre-hospitalSTEMIactivationofthecatheterisationlaboratory may not only reduce treatment delays but may also reduce patientmortality.
• Theuseofnegativehigh-sensitivitycardiactroponins(hs-cTn) duringinitialpatientevaluationcannotbeusedasastandalone measuretoexcludeanACS,butinpatientswithverylowrisk scoresmayjustifyearlydischarge.
TherapeuticInterventionsinACS
• Adenosinediphosphate(ADP)receptorantagonists(clopidogrel, ticagrelor,orprasugrel-withspecificrestriction),maybegiven eitherpre-hospitalorintheEDforSTEMIpatientsplannedfor primaryPCI.
• Unfractionatedheparin(UFH)canbeadministeredeitherinthe pre-hospitalorin-hospitalsettinginpatientswithSTEMIanda plannedprimaryPCIapproach.
• Pre-hospitalenoxaparinmaybeusedasanalternativeto pre-hospitalUFHforSTEMI.
• PatientswithacutechestpainwithpresumedACSdonotneed supplementaloxygenunlesstheypresentwithsignsofhypoxia, dyspnoea,orheartfailure.
ReperfusiondecisionsinSTEMI
Reperfusiondecisionshavebeenreviewedinavarietyof possi-blelocalsituations.
• Whenfibrinolysisistheplannedtreatmentstrategy,we recom-mendusingpre-hospitalfibrinolysisincomparisontoin-hospital fibrinolysisfor STEMIwhere transport timesare>30minand pre-hospitalpersonnelarewelltrained.
• IngeographicregionswherePCIfacilitiesexistandareavailable, directtriageand transportfor PCIispreferredtopre-hospital fibrinolysisforSTEMI.
• PatientspresentingwithSTEMIintheemergencydepartment (ED) of a non-PCI capable hospital should be transported immediately to a PCI centre provided that treatment delays for PPCI are less than 120min (60–90min for early presen-tersand those withextended infarctions), otherwise patients should receive fibrinolysis and be transported to a PCI centre.
• Patients who receive fibrinolytic therapy in the emergency departmentofanon-PCIcentreshouldbetransportedif possi-bleforearlyroutineangiography(within3–24hfromfibrinolytic therapy)ratherthanbetransportedonlyifindicatedbythe pres-enceofischaemia.
• PCIinlessthan3hfollowingadministrationoffibrinolyticsis notrecommendedandcanbeperformedonlyincaseoffailed fibrinolysis.
Hospitalreperfusiondecisionsafterreturnofspontaneous circulation
• We recommend emergency cardiac catheterisation lab eval-uation (and immediate PCI if required), in a manner similar to patients with STEMI without cardiac arrest, in selected adult patients with ROSC after out-of-hospital cardiac arrest (OHCA) of suspected cardiac origin with ST-elevation on ECG.
• InpatientswhoarecomatoseandwithROSCafterOHCAof sus-pectedcardiacoriginwithoutST-elevationonECGItisreasonable
toconsideranemergencycardiaccatheterisationlabevaluation inpatientswiththehighestriskofcoronarycausecardiacarrest.
Firstaid
Asectiononfirstaidisincludedforthefirsttimeinthe2015 ERCGuidelines.
Principlesofeducationinresuscitation
Thefollowingisasummaryofthemostimportantnewviewsor changesinrecommendationsforeducationinresuscitationsince thelastERCguidelinesin2010.
Training
• Incentresthathavetheresourcestopurchaseandmaintainhigh fidelitymanikins,we recommendtheiruse. The useof lower fidelitymanikinshoweverisappropriateforalllevelsoftraining onERCcourses.
• DirectiveCPRfeedbackdevices areusefulforimproving com-pressionrate,depth, release,andhandposition.Tonaldevices improvecompression rates onlyand may havea detrimental effectoncompressiondepthwhilerescuersfocusontherate. • Theintervalsforretrainingwilldifferaccordingtothe
character-isticsoftheparticipants(e.g.layorhealthcare).Itisknownthat CPRskillsdeterioratewithinmonthsoftrainingandtherefore annualretrainingstrategiesmaynotbefrequentenough.Whilst optimalintervalsarenotknown,frequent‘lowdose’retraining maybebeneficial.
• Traininginnon-technicalskills(e.g.communicationskills,team leadershipandteam memberroles)is anessentialadjunctto thetraining oftechnicalskills.Thistypeof trainingshouldbe incorporatedintolifesupportcourses.
• Ambulanceservicedispatchershaveaninfluentialroletoplayin guidinglayrescuershowtodeliverCPR.Thisroleneedsspecific traininginordertodeliverclearandeffectiveinstructionsina stressfulsituation.
Implementation
• Data-drivenperformance-focuseddebriefinghasbeenshownto improveperformanceofresuscitationteams.Wehighly recom-menditsuseforteamsmanagingpatientsincardiacarrest. • Regional systems including cardiac arrest centres are to be
encouraged,asthereisanassociationwithincreasedsurvival andimprovedneurologicaloutcomeinvictimsofout-of-hospital cardiacarrest.
• Novelsystemsare beingdevelopedtoalert bystanderstothe locationofthenearestAED.Anytechnologythatimprovesthe deliveryofswiftbystanderCPRwithrapidaccesstoanAEDisto beencouraged.
• “It takes a system to save a life” [http://www. resuscitationacademy.com/].Healthcaresystemswitha respon-sibilityfor themanagement of patientsin cardiac arrest(e.g. EMSorganisations,cardiacarrestcentres)shouldevaluatetheir processestoensurethattheyareabletodelivercarethatensures thebestachievablesurvivalrates.
Theethicsofresuscitationandend-of-lifedecisions
The2015ERCGuidelinesincludeadetaileddiscussionofthe ethicalprinciplesunderpinningcardiopulmonaryresuscitation.
Theinternationalconsensusoncardiopulmonary resuscitationscience
TheInternationalLiaisonCommitteeonResuscitation(ILCOR, www.ilcor.org)includesrepresentativesfromtheAmericanHeart Association(AHA),theEuropeanResuscitationCouncil(ERC),the HeartandStrokeFoundationofCanada(HSFC),theAustralianand NewZealandCommitteeonResuscitation(ANZCOR),the Resusci-tationCouncilofSouthernAfrica(RCSA),theInter-AmericanHeart Foundation (IAHF),andtheResuscitationCouncilof Asia(RCA). Since 2000, researchersfrom theILCOR member councils have evaluatedresuscitationsciencein5-yearlycycles.Themostrecent InternationalConsensusConferencewasheldinDallasinFebruary 2015andthepublishedconclusionsandrecommendationsfrom thisprocessformthebasisoftheseERCGuidelines2015.14
InadditiontothesixILCORtaskforcesfrom2010(basiclife sup-port(BLS);advancedlifesupport(ALS);acutecoronarysyndromes (ACS);paediatriclifesupport(PLS);neonatallifesupport(NLS); andeducation,implementationandteams(EIT))aFirstAidtask forcewascreated.Thetaskforcesidentifiedtopicsrequiring evi-denceevaluationandinvitedinternationalexpertstoreviewthem. Asin2010,acomprehensiveconflictofinterest(COI)policywas applied.14
For eachtopic,two expertreviewerswereinvitedto under-takeindependentevaluations.Theirworkwassupportedbyanew anduniqueonlinesystemcalledSEERS(ScientificEvidence Eval-uationand Review System),developed by ILCOR.To assess the qualityoftheevidenceandthestrengthoftherecommendations, ILCORadoptedtheGRADE(GradingofRecommendations Assess-ment, Development and Evaluation) methodology.15 TheILCOR 2015ConsensusConferencewasattendedby232participants rep-resenting39countries;64%oftheattendeescamefromoutside theUnitedStates.Thisparticipationensuredthatthisfinal publica-tionrepresentsatrulyinternationalconsensusprocess.Duringthe threeyearsleadinguptothisconference,250evidencereviewers from39countriesreviewedthousandsofrelevant,peer-reviewed publicationstoaddress169specificresuscitationquestions,each inthestandardPICO(Population,Intervention,Comparison, Out-come)format.Each sciencestatementsummarised theexperts’ interpretationof allrelevant dataonthespecific topicand the relevantILCORtaskforceaddedconsensusdrafttreatment recom-mendations.Finalwordingofsciencestatementsand treatment recommendationswascompletedafterfurtherreviewbyILCOR memberorganisationsandbytheeditorialboard,andpublished in Resuscitationand Circulationas the2015Consensus on Sci-enceandTreatmentRecommendations(CoSTR).16,17Themember organisationsformingILCORwillpublishresuscitationguidelines thatareconsistentwiththisCoSTRdocument,butwillalso con-sidergeographic,economicandsystemdifferencesinpractice,and theavailabilityofmedicaldevicesanddrugs.
Fromsciencetoguidelines
TheseERCGuidelines2015arebasedonthe2015CoSTR doc-umentandrepresentconsensusamongthemembersoftheERC GeneralAssembly.NewtotheERCGuidelines2015aretheFirstAid Guidelines,createdinparallelwiththeFirstAidTaskForceofILCOR, andguidelinesonpost-resuscitationcare.Foreachsectionofthe ERCGuidelines2015,awritinggroupwasassignedthatdraftedand agreedonthemanuscriptpriortoapprovalbytheGeneral Assem-blyandtheERCBoard.InareaswhereILCORhadnotconducteda systematicreview,theERCwritinggroupundertookfocused litera-turereviews.TheERCconsidersthesenewguidelinestobethemost effectiveandeasilylearnedinterventionsthatcanbesupported bycurrentknowledge,researchandexperience.Inevitably,even
withinEurope,differencesintheavailabilityofdrugs,equipment, andpersonnelwillnecessitatelocal,regionalandnational adapta-tionoftheseguidelines.Someoftherecommendationsmadeinthe ERCGuidelines2010remainunchangedin2015,eitherbecauseno newstudieshavebeenpublishedorbecausenewevidencesince 2010hasmerelystrengthenedtheevidencethatwasalready avail-able.
Adultbasiclifesupportandautomatedexternal defibrillation
Thebasiclifesupport(BLS) andautomatedexternal defibril-lation(AED) chaptercontains guidanceon thetechniquesused duringtheinitialresuscitationofanadultcardiacarrest victim. ThisincludesBLS(airway,breathingandcirculationsupport with-outtheuseofequipmentotherthanaprotectivedevice)andtheuse ofanAED.Inaddition,simpletechniquesusedinthemanagement ofchoking(foreignbodyairwayobstruction)areincluded. Guide-linesfortheuseofmanualdefibrillatorsandstartingin-hospital resuscitationarefoundinsection3.2Asummaryoftherecovery positionisincluded,withfurtherinformationprovidedintheFirst AidChapter.
TheguidelinesarebasedontheILCOR2015Consensuson Sci-enceandTreatmentRecommendations(CoSTR)forBLS/AED.18The ILCORreviewfocusedon23keytopicsleadingto32Treatment Rec-ommendationsinthedomainsofearlyaccessandcardiacarrest prevention,early,high-qualityCPR,andearlydefibrillation.
Cardiacarrest
Suddencardiacarrest(SCA)isoneoftheleadingcausesofdeath inEurope.Oninitialheart-rhythmanalysis,about25–50%ofSCA victimshaveventricularfibrillation(VF)19–21butwhentherhythm isrecordedsoonaftercollapse,inparticularbyanon-siteAED,the proportionofvictimsinVFcanbeashighas76%.22,23The recom-mendedtreatmentforVFcardiacarrest isimmediatebystander CPRandearlyelectricaldefibrillation.Mostcardiacarrestsof non-cardiacoriginhaverespiratorycauses,suchasdrowning(among themmanychildren)andasphyxia.Rescuebreathsaswellaschest compressionsarecriticalforsuccessfulresuscitationofthese vic-tims.
Thechainofsurvival
TheChainofSurvivalsummarisesthevitallinksneededfor suc-cessfulresuscitation(Fig.1.2).Mostoftheselinksapplytovictims ofbothprimarycardiacandasphyxialarrest.13
1:Earlyrecognitionandcallforhelp
Recognisingthecardiac originof chest pain,and callingthe emergencyservicesbeforeavictimcollapses,enablesthe emer-gencymedical servicetoarrivesooner,hopefully beforecardiac arresthasoccurred,thusleadingtobettersurvival.24–26
Oncecardiacarresthasoccurred,earlyrecognitioniscritical toenable rapid activationof the EMS and prompt initiationof bystanderCPR.Thekeyobservationsareunresponsivenessandnot breathingnormally.
2:EarlybystanderCPR
TheimmediateinitiationofCPRcandoubleorquadruple sur-vivalaftercardiacarrest.27–29Ifable,bystanderswithCPRtraining shouldgivechestcompressionstogetherwithventilations.Whena bystanderhasnotbeentrainedinCPR,theemergencymedical dis-patchershouldinstructhimorhertogivechest-compression-only CPRwhileawaitingthearrivalofprofessionalhelp.30–32
3:Earlydefibrillation
Defibrillationwithin3–5minofcollapsecanproducesurvival ratesashighas50–70%.Thiscanbeachievedbypublicaccessand onsiteAEDs.21,23,33
4:Earlyadvancedlifesupportandstandardisedpost-resuscitation care
Advanced life support with airway management, drugs and correctingcausalfactorsmaybeneededifinitialattemptsat resus-citationareun-successful.
Thecriticalneedforbystanderstoact
In most communities, the median time from emergency callto emergency medical service arrival (responseinterval) is 5–8min,22,34–36or8–11mintoafirstshock.21,28Duringthistime thevictim’ssurvivaldependsonbystanderswhoinitiateCPRand useanautomatedexternaldefibrillator(AED).22,37
Recognitionofcardiacarrest
Recognisingcardiacarrestcanbechallenging.Bothbystanders and emergency call handlers (emergency medical dispatchers) have to diagnose cardiac arrest promptly in order to activate thechain of survival. Checking the carotid pulse(or anyother pulse)hasprovedtobeaninaccuratemethodforconfirmingthe presenceorabsenceofcirculation.38–42Agonalbreathingmaybe presentinupto40%ofvictimsinthefirstminutesaftercardiac arrest,andifrespondedtoasasignofcardiacarrest,isassociated withhigher survival rates.43 The significance of agonal breath-ingshouldbeemphasisedduringbasiclifesupporttraining.44,45 BystandersshouldsuspectcardiacarrestandstartCPRifthe vic-timisunresponsiveandnotbreathingnormally.Bystandersshould be suspicious of cardiac arrest in any patient presenting with seizures.46,47
Roleoftheemergencymedicaldispatcher
Dispatcherrecognitionofcardiacarrest
Patients who are unresponsive and not breathing normally shouldbepresumedtobeincardiacarrest.Agonalbreathingis oftenpresent, and callersmay mistakenlybelieve thevictim is stillbreathingnormally.48–57Offeringdispatchersadditional edu-cation,specificallyaddressingtheidentificationandsignificanceof agonalbreathing,canimprovecardiacarrestrecognition,increase theprovision of telephone-CPR,55,57 and reduce thenumber of missedcardiacarrestcases.52
Iftheinitialemergencycallisforapersonsufferingseizures,the calltakershouldbehighlysuspiciousofcardiacarrest,evenifthe callerreportsthatthevictimhasapriorhistoryofepilepsy.49,58
Dispatcher-assistedCPR
BystanderCPRratesarelowinmanycommunities. Dispatcher-assisted CPR (telephone-CPR) instructions improve bystander CPRrates,56,59–62reducethetimetofirstCPR,57,59,62–64 increase the number of chest compressions delivered60 and improve patientoutcomesfollowingout-of-hospitalcardiacarrest(OHCA) in all patient groups.30–32,56,61,63,65 Dispatchers should provide telephone-CPRinstructionsinallcasesofsuspectedcardiacarrest unlessatrainedproviderisalreadydeliveringCPR.Where instruc-tionsarerequiredforanadultvictim,dispatchersshouldprovide chest-compression-onlyCPRinstructions.Ifthevictimisachild, dispatchersshouldinstructcallerstoprovidebothventilationsand chestcompressions.
AdultBLSsequence
Fig. 1.3 presents the step-by-step sequence for the trained provider.Itcontinuestohighlighttheimportanceofensuring res-cuer,victimand bystandersafety.Calling foradditionalhelp (if required)isincorporatedinthealertingemergencyservicesstep below.Forclaritythealgorithmispresentedasalinearsequence ofsteps.Itisrecognisedthattheearlystepsofcheckingresponse, openingtheairway,checkingforbreathingandcallingthe emer-gencymedicaldispatchermaybeaccomplishedsimultaneouslyor inrapidsuccession.
Thosewhoarenottrainedtorecognisecardiacarrestandstart CPRwouldnotbeawareoftheseguidelinesandthereforerequire dispatcherassistancewhenevertheymakethedecisiontocall112 (Fig.1.4).
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.1.3.Thebasiclifesupport/automatedexternaldefibrillation(BLS/AED) algo-rithm.
Openingtheairwayandcheckingforbreathing
Thetrainedprovidershouldassessthecollapsedvictimrapidly todetermineiftheyareresponsiveandbreathingnormally.Open the airway using the head tilt and chin lift technique whilst assessingwhetherthepersonisbreathingnormally.
Alertingemergencyservices
112istheEuropeanemergencyphonenumber,available every-where in theEU,free of charge. It is possibletocall112 from fixedand mobilephonesto contactany emergencyservice:an ambulance,thefirebrigadeorthepolice.Earlycontactwiththe emergency services will facilitate dispatcher assistance in the recognitionofcardiacarrest,telephoneinstructiononhowto per-formCPR,emergencymedicalservice/firstresponderdispatch,and onlocatinganddispatchingofanAED.66–69
Startingchestcompressions
InadultsneedingCPR,thereisahighprobabilityofaprimary cardiaccause.Whenbloodflowstopsaftercardiacarrest,theblood in the lungs and arterialsystem remains oxygenated for some minutes.Toemphasisethepriorityofchestcompressions,itis rec-ommendedthatCPRshouldstartwithchestcompressionsrather thaninitialventilations.
Whenprovidingmanualchestcompressions: 1.Delivercompressions‘inthecentreofthechest’
2.Compresstoadepthofatleast5cmbutnotmorethan6cm 3.Compressthechestatarateof100–120min−1withasfew
inter-ruptionsaspossible
4.Allowthechesttorecoilcompletelyaftereachcompression;do notleanonthechest
Handposition
Experimental studies show better haemodynamic responses whenchestcompressionsareperformedonthelowerhalfofthe
Fig.1.4. (Continued)
sternum.70–72Itisrecommendedthatthislocationbetaughtina simplifiedway,suchas,“placetheheelofyourhandinthecentre ofthechestwiththeotherhandontop”.Thisinstructionshouldbe accompaniedbyademonstrationofplacingthehandsonthelower halfofthesternum.73,74
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.75,76
Compressiondepth
Data from four recent observational studies suggest that a compression depth range of 4.5–5.5cm in adults leads to bet-teroutcomesthanall othercompressiondepthsduringmanual CPR.77–80Oneofthesestudiesfoundthatacompressiondepthof 46mmwasassociatedwiththehighestsurvivalrate.79TheERC, therefore,endorsestheILCORrecommendationthatitis reason-abletoaimforachestcompressiondepthofapproximately5cm butnotmorethan6cmintheaveragesizedadult.81Inlinewith theILCORrecommendation, theERC decidedtoretainthe2010 guidancetocompressthechestatleast5cmbutnotmorethan 6cm.
Compressionrate
Twostudiesfoundhighersurvivalamongpatientswhoreceived chestcompressionsatarateof100–120min−1.Veryhighchest compression rates were associated with declining chest com-pressiondepths.82,83TheERCrecommends,therefore,thatchest compressionsshouldbeperformedatarateof100–120min−1.
Minimisingpausesinchestcompressions
Pre-andpost-shockpausesoflessthan10s,andchest compres-sionfractions>60%areassociatedwithimprovedoutcomes.84–88 Pausesinchestcompressionsshouldbeminimised.
Firmsurface
CPRshouldbeperformedona firmsurface whenever possi-ble.Air-filledmattressesshouldberoutinelydeflatedduringCPR.89 Theevidencefortheuseofbackboardsisequivocal.90–94Ifa back-boardisused,takecaretoavoidinterruptingCPRanddislodging intravenouslinesorothertubesduringboardplacement.
Chestwallrecoil
Allowingcompleterecoilofthechestaftereachcompression resultsinbettervenousreturntothechestandmayimprovethe effectivenessofCPR.95–98CPRprovidersshould,therefore,takecare toavoidleaningaftereachchestcompression.
Dutycycle
Thereis verylittleevidencetorecommendanyspecificduty cycleand,therefore,insufficientnewevidencetopromptachange fromthecurrentlyrecommendedratioof50%.
Feedbackoncompressiontechnique
Noneofthestudiesonfeedbackorpromptdeviceshas demon-stratedimprovedsurvivaltodischargewithfeedback.99Theuseof CPRfeedbackorpromptdevicesduringCPRshouldonlybe con-sideredas partof abroadersystemof carethatshouldinclude comprehensiveCPRqualityimprovement initiatives,99,100 rather thanasanisolatedintervention.
Rescuebreaths
We suggest that during adultCPR tidal volumesof approx-imately500–600ml (6–7mlkg−1)aredelivered.Practically, this isthevolumerequiredtocausethechesttorisevisibly.101 CPR providersshouldaimforaninflationdurationofabout1s,with enoughvolumetomakethevictim’schestrise,butavoidrapidor forcefulbreaths.Themaximuminterruptioninchestcompression togivetwobreathsshouldnotexceed10s.102
Compression–ventilationratio
A ratio of 30:2 was recommended in ERC Guidelines 2010 forthesingleCPRproviderattemptingresuscitationofanadult. Several observational studies have reported slightly improved outcomesafterimplementationof theguidelinechanges, which includedswitchingfromacompressionventilationratioof15:2to 30:2.103–106TheERCcontinues,therefore,torecommenda com-pressiontoventilationratioof30:2.
Compression-onlyCPR
Observationalstudies,classifiedmostlyasverylow-quality evi-dence,havesuggestedequivalenceofchest-compression-onlyCPR andchestcompressionscombinedwithrescuebreathsinadults witha suspectedcardiac causefortheircardiacarrest.27,107–118 Ourconfidence in theequivalence between chest-compression-onlyandstandardCPRisnotsufficienttochangecurrentpractice. TheERC,therefore,endorsestheILCORrecommendationsthatall CPRprovidersshouldperformchestcompressionsforallpatients incardiacarrest.CPRproviderstrainedandabletoperform res-cuebreathsshouldperformchestcompressionsandrescuebreaths asthismayprovideadditionalbenefitforchildrenandthosewho sustainan asphyxial cardiac arrest111,119,120 or where the EMS responseintervalisprolonged.115
Useofanautomatedexternaldefibrillator
AEDsaresafeandeffectivewhenusedbylaypeoplewith min-imalornotraining.121AEDsmakeitpossibletodefibrillatemany minutesbeforeprofessionalhelparrives.CPRprovidersshould con-tinueCPRwithminimalinterruptionofchestcompressionswhile attachinganAEDandduringitsuse.CPRprovidersshould con-centrateonfollowingthevoicepromptsimmediatelywhenthey arespoken,inparticularresumingCPRassoonasinstructed,and minimisinginterruptionsinchestcompression.StandardAEDsare suitableforuseinchildrenolderthan8years.122–124Forchildren between1and8yearsusepaediatricpads,togetherwithan atten-uatororapaediatricmodeifavailable.
CPRbeforedefibrillation
ContinueCPRwhileadefibrillatororAEDisbeingbrought on-siteandapplied,butdefibrillationshouldnotbedelayedanylonger. Intervalbetweenrhythmchecks
Pausechest compressionsevery 2min toassess the cardiac rhythm.
Voiceprompts
Itis criticallyimportant thatCPR providerspayattentionto AED voice prompts and follow them without any delay.Voice promptsareusuallyprogrammable,anditisrecommendedthat theybesetinaccordancewiththesequenceofshocksandtimings
forCPRgivenabove.DevicesmeasuringCPRqualitymayin addi-tionprovidereal-timeCPRfeedbackandsupplementalvoice/visual prompts.
Inpractice,AEDsareusedmostlybytrainedrescuers,where thedefaultsettingofAEDpromptsshouldbeforacompressionto ventilationratioof30:2.If(inanexception)AEDsareplacedina settingwheresuchtrainedrescuersareunlikelytobeavailableor present,theownerordistributormaychoosetochangethesettings tocompressiononly.
Publicaccessdefibrillation(PAD)programmes
PlacementofAEDsinareaswhereonecardiacarrestper5years canbeexpectedis consideredcost-effectiveand comparableto othermedicalinterventions.125–127RegistrationofAEDsforpublic access,sothatdispatcherscandirectCPRproviderstoanearbyAED, mayalsohelptooptimiseresponse.128TheeffectivenessofAEDuse forvictimsathomeislimited.129Theproportionofpatientsfound inVFislowerathomethaninpublicplaces,howevertheabsolute numberofpotentiallytreatablepatientsishigherathome.129 Pub-licaccessdefibrillation(PAD)rarelyreachesvictimsathome.130 DispatchedlayCPRproviders,localtothevictimanddirectedtoa nearbyAED,mayimprovebystanderCPRrates33andhelpreduce thetimetodefibrillation.37
UniversalAEDsignage
ILCORhasdesignedasimpleandclearAEDsignthatmaybe recognisedworldwide andthis isrecommendedtoindicatethe locationofanAED.131
In-hospitaluseofAEDs
Therearenopublishedrandomisedtrialscomparingin-hospital useofAEDswithmanualdefibrillators.Threeobservationalstudies showednoimprovementsinsurvivaltohospitaldischargefor in-hospitaladultcardiacarrestwhenusinganAEDcomparedwith manual defibrillation.132–134 Another large observational study showed that in-hospital AED use wasassociated with a lower survival-to-dischargeratecomparedwithnoAEDuse.135This sug-gests that AEDs may cause harmful delays in starting CPR, or interruptionsinchestcompressionsinpatientswithnon-shockable rhythms.136WerecommendtheuseofAEDsinthoseareasofthe hospitalwherethereisariskofdelayeddefibrillation,137becauseit willtakeseveralminutesforaresuscitationteamtoarrive,andfirst respondersdonothaveskillsinmanualdefibrillation.Thegoalis toattemptdefibrillationwithin3minofcollapse.Inhospitalareas wherethereisrapidaccesstomanualdefibrillation,eitherfrom trainedstafforaresuscitationteam,manualdefibrillationshould beusedinpreferencetoanAED.Hospitalsshouldmonitor collapse-to-firstshockintervalsandauditresuscitationoutcomes.
RiskstotheCPRproviderandrecipientsofCPR
In victims who are eventually found not to be in cardiac arrest,bystanderCPRextremelyrarelyleadstoseriousharm.CPR providersshouldnot,therefore,bereluctanttoinitiateCPRbecause ofconcernofcausingharm.
Foreignbodyairwayobstruction(choking)
Foreignbodyairwayobstruction(FBAO)isanuncommonbut potentiallytreatablecauseofaccidentaldeath.138Asvictims ini-tiallyareconsciousandresponsive,thereareoftenopportunities forearlyinterventionswhichcanbelifesaving.
Recognition
FBAO usually occurs while the victim is eatingor drinking. Fig.1.5presentsthetreatmentalgorithmfortheadultwithFBAO. Foreignbodiesmaycauseeithermildorsevereobstruction.Itis importanttoasktheconsciousvictim“Areyouchoking?”.The vic-timthatisabletospeak,coughandbreathehasmildobstruction.
Thevictimthatisunabletospeak,hasaweakeningcough,is strug-glingorunabletobreathe,hassevereairwayobstruction. Treatmentformildairwayobstruction
Encouragethevictimtocoughascoughinggenerateshighand sustainedairwaypressuresandmayexpeltheforeignbody.
Fig.1.5. (Continued)
Treatmentforsevereairwayobstruction
Forconsciousadultsandchildrenoveroneyearofagewith com-pleteFBAO,casereportshavedemonstratedtheeffectivenessof backblowsor‘slaps’,abdominalthrustsandchestthrusts.139The likelihoodofsuccessisincreasedwhencombinationsofbackblows orslaps,andabdominalandchestthrustsareused.139
Treatmentofforeignbodyairwayobstructioninanunresponsive victim
Arandomisedtrialincadavers140 and twoprospective stud-iesinanaesthetisedvolunteers141,142showedthathigherairway pressurescan begenerated using chest thrusts compared with abdominal thrusts. Chest compressions should, therefore, be startedpromptlyifthevictim becomesunresponsiveor uncon-scious. After 30 compressions attempt 2 rescue breaths, and continueCPRuntilthevictimrecoversandstartstobreathe nor-mally.
Victimswitha persistentcough,difficultyswallowingorthe sensationofan object beingstill stuckin thethroat shouldbe referredforamedicalopinion.Abdominalthrustsandchest com-pressionscan potentiallycause seriousinternal injuries and all victimssuccessfullytreatedwiththesemeasuresshouldbe exam-inedafterwardsforinjury.
Resuscitationofchildren(seealsosection6)andvictimsof drowning(seealsosection4)
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).
Adultadvancedlifesupport
Guidelinesforpreventionofin-hospitalcardiacarrest
Earlyrecognitionofthedeterioratingpatientandpreventionof cardiacarrestisthefirstlinkinthechainofsurvival.13Oncecardiac arrestoccurs,onlyabout20%ofpatientswhohaveanin-hospital cardiac arrest will survive to go home.143,144 Hospitals should provideasystemofcarethatincludes:(a)educatingstaffaboutthe signsofpatientdeteriorationandtherationaleforrapidresponseto illness,(b)appropriate,andfrequentmonitoringofpatients’vital signs,(c)clearguidance(e.g.viacallingcriteriaorearlywarning scores)toassiststaffintheearlydetectionofpatient deteriora-tion,(d)aclear,uniformsystemofcallingforassistance,and(e)an appropriateandtimelyclinicalresponsetocallsforhelp.145 Preventionofsuddencardiacdeath(SCD)out-of-hospital
Most SCD victims have a history of cardiac disease and warning signs, most commonly chest pain, in the hour before cardiacarrest.146 Apparently healthychildren andyoungadults who suffer SCD can also have signs and symptoms (e.g. syncope/pre-syncope,chestpainandpalpitations)thatshouldalert healthcare professionals toseekexpert help topreventcardiac arrest.147–151 Screening programmes for athletesvary between countries.152,153 Identificationofindividuals withinherited con-ditionsandscreeningoffamilymemberscanhelppreventdeaths inyoungpeoplewithinheritedheartdisorders.154–156
Prehospitalresuscitation
CPRversusdefibrillationfirstforout-of-hospitalcardiacarrest EMSpersonnelshouldprovidehigh-qualityCPRwhilea defibril-latorisretrieved,appliedandcharged.Defibrillationshouldnotbe delayedlongerthanneededtoestablishtheneedfordefibrillation andcharging.
Terminationofresuscitationrules
The‘basiclifesupportterminationofresuscitationrule’is pre-dictiveof deathwhenappliedby defibrillation-onlyemergency medicaltechnicians.157Therulerecommendsterminationwhen thereisnoROSC,noshocksareadministeredandEMSpersonnel didnot witnessthearrest. Severalstudieshaveshown external generalisabilityofthisrule.158–164Morerecentstudiesshowthat EMSsystemsprovidingALSinterventionscanalsousethisBLSrule andthereforetermeditthe‘universal’terminationofresuscitation rule.159,165,166
In-hospitalresuscitation
After in-hospital cardiac arrest, the division between BLS and ALS is arbitrary; in practice, the resuscitationprocess is a
Collapsed / sick p
atient
Shout
for HELP & assess patient
Signs of life?
No
Yes
Call resuscitation
team
CPR 30:2
with oxygen and
airway adjun
cts
Apply pads/monitor
Attempt defib
rill
ation
if approp
riate
Advan
ced Li
fe Suppo
rt
when resuscitation
team arr
ives
Assess ABCDE
Recognise & t
reat
Oxygen, moni
torin
g,
IV access
Call
resuscit
ation
team
if approp
riate
Handover
to
resuscit
ation
team
In-hospital Resuscit
ation
Fig.1.6.In-hospitalresuscitationalgorithm.ABCDE–Airway,BreathingCirculation,Disability,ExposureIV–intravenous;CPR–cardiopulmonaryresuscitation.
continuumandisbasedoncommonsense.Analgorithmforthe initialmanagementofin-hospitalcardiacarrestisshowninFig.1.6.
• Ensurepersonalsafety.
• Whenhealthcareprofessionalsseeapatientcollapseorfinda patientapparentlyunconscious ina clinicalarea, theyshould firstsummonhelp(e.g.emergencybell,shout),thenassessifthe patientisresponsive.Gentlyshaketheshouldersandaskloudly: ‘Areyouallright?’
• Ifothermembersofstaffarenearby,itwillbepossibleto under-takeactionssimultaneously.
Theresponsivepatient
Urgent medical assessment is required. Depending on the localprotocols, this may taketheform ofa resuscitationteam (e.g. Medical Emergency Team, Rapid Response Team). While
awaitingthisteam,giveoxygen,attachmonitoringandinsertan intravenouscannula.
Theunresponsivepatient
Theexact sequence willdependonthetraining of staffand experience in assessment of breathing and circulation. Trained healthcarestaffcannotassessthebreathingandpulsesufficiently reliablytoconfirmcardiacarrest.39,40,42,44,167–172
Agonal breathing (occasional gasps, slow, laboured or noisy breathing)iscommonintheearlystagesofcardiacarrestandis asignofcardiacarrestand shouldnotbeconfusedasa signof life.43,53,54,56Agonalbreathingcanalsooccurduringchest com-pressionsascerebralperfusionimproves,butisnotindicativeof ROSC.Cardiacarrestcancauseaninitialshortseizure-likeepisode that canbe confusedwithepilepsy46,47 Finally changes in skin colour,notablypallorandbluishchangesassociatedwithcyanosis arenotdiagnosticofcardiacarrest.46
• Shoutforhelp(ifnotalready)
Turnthevictimontohisbackandthenopentheairway: • Openairwayandcheckbreathing:
◦Opentheairwayusingaheadtiltchinlift
◦Keeping the airway open, look, listen and feel for normal breathing(anoccasionalgasp,slow,labouredornoisy breath-ingisnotnormal):
• Lookforchestmovement
• Listenatthevictim’smouthforbreathsounds • Feelforaironyourcheek
• Look,listenandfeelfornomorethan10secondstodetermineif thevictimisbreathingnormally.
• Checkforsignsofacirculation:
◦It maybedifficulttobecertainthatthereisnopulse.Ifthe patienthasnosignsoflife(consciousness,purposeful move-ment,normalbreathing,orcoughing),orifthereisdoubt,start CPRimmediatelyuntilmoreexperiencedhelparrivesorthe patientshowssignsoflife.
◦Deliveringchestcompressionstoapatientwithabeatingheart isunlikelytocauseharm.173However,delaysindiagnosing car-diacarrestandstartingCPRwilladverselyeffectsurvivaland mustbeavoided.
◦OnlythoseexperiencedinALSshouldtrytoassessthecarotid pulsewhilstsimultaneouslylookingforsignsoflife.Thisrapid assessmentshouldtakenomorethan10s.StartCPRifthereis anydoubtaboutthepresenceorabsenceofapulse.
• Iftherearesignsoflife,urgentmedicalassessmentisrequired. Dependingonthelocalprotocols,this maytaketheformofa resuscitationteam.While awaitingthis team,givethepatient oxygen,attachmonitoringand insertanintravenous cannula. Whenareliablemeasurementofoxygensaturationofarterial blood(e.g.pulseoximetry(SpO2))canbeachieved,titratethe inspiredoxygenconcentrationtoachieveaSpO2of94–98%. • Ifthereisnobreathing,butthereisapulse(respiratoryarrest),
ventilatethepatient’slungsandcheckforacirculationevery10 breaths.Start CPRifthereisanydoubtaboutthepresenceor absenceofapulse.
Startingin-hospitalCPR
Thekeystepsarelistedhere.Supportingevidencecanbefound inthesectionsonspecificinterventionsthatfollow.
• One person starts CPR as others call the resuscitation team and collecttheresuscitation equipmentand a defibrillator. If onlyonememberofstaffispresent,thiswillmeanleavingthe patient.
• Give30chestcompressionsfollowedby2ventilations. • Compresstoadepthofatleast5cmbutnomorethan6cm. • Chest compressions should be performed at a rate of
100–120min−1.
• Allowthechesttorecoilcompletelyaftereachcompression;do notleanonthechest.
• Minimiseinterruptionsandensurehigh-qualitycompressions. • Undertaking high-qualitychest compressionsfor a prolonged
timeistiring;withminimalinterruption,trytochangetheperson doingchestcompressionsevery2min.
• Maintaintheairwayandventilatethelungswiththemost appro-priateequipmentimmediatelytohand.Pocketmaskventilation or two-rescuer bag-mask ventilation, which can be supple-mentedwithanoralairway,shouldbestarted.Alternatively,use asupraglotticairwaydevice(SGA)andself-inflatingbag.Tracheal intubationshouldbeattemptedonlybythosewhoaretrained, competentandexperiencedinthisskill.
• Waveformcapnography mustbeusedfor confirmingtracheal tube placement and monitoring ventilation rate. Waveform
capnographycanalsobeusedwithabag-maskdeviceandSGA. ThefurtheruseofwaveformcapnographytomonitorCPRquality andpotentiallyidentifyROSCduringCPRisdiscussedlaterinthis section.174
• Useaninspiratorytimeof1sandgiveenoughvolumetoproduce anormalchestrise.Addsupplementaloxygentogivethehighest feasibleinspiredoxygenassoonaspossible.175
• Oncethepatient’stracheahasbeenintubatedoraSGAhasbeen inserted, continue uninterrupted chest compressions (except fordefibrillationor pulsecheckswhen indicated)ata rateof 100–120min−1 and ventilate the lungs at approximately 10 breathsmin−1.Avoidhyperventilation(bothexcessiverateand tidalvolume).
• Ifthereisnoairwayandventilationequipmentavailable, con-sider giving mouth-to-mouth ventilation. If there are clinical reasonstoavoidmouth-to-mouthcontact,oryouareunableto dothis,dochestcompressionsuntilhelporairwayequipment arrives.
• Whenthedefibrillatorarrives,applyself-adhesivedefibrillation padstothepatientwhilstchestcompressionscontinueandthen brieflyanalysetherhythm. Ifself-adhesivedefibrillationpads arenotavailable,usepaddles.Pausebrieflytoassesstheheart rhythm.With a manual defibrillator,if therhythm is VF/pVT chargethedefibrillatorwhile anotherrescuercontinueschest compressions.Oncethedefibrillatorischarged,pausethechest compressionsandthengiveoneshock,andimmediatelyresume chestcompressions.Ensurenooneistouchingthepatient dur-ingshockdelivery.Planandensuresafedefibrillationbeforethe plannedpauseinchestcompressions.
• If using an automated external defibrillator (AED) follow the AED’s audio-visual prompts, and similarly aim to min-imise pauses in chest compressions by rapidly following prompts.
• Insomesettingswhereself-adhesivedefibrillationpadsarenot available,alternativedefibrillationstrategiesusingpaddlesare usedtominimisethepreshockpause.
• Insomecountriesadefibrillationstrategythatinvolvescharging thedefibrillatortowardstheendofevery2mincycleofCPRin preparationforthepulsecheckisused.176,177Iftherhythmis VF/pVTashockisgivenandCPRresumed.Whetherthisleadsto anybenefitisunknown,butitdoesleadtodefibrillatorcharging fornon-shockablerhythms.
• Restartchestcompressionsimmediatelyafterthedefibrillation attempt.Minimiseinterruptionstochestcompressions. When usingamanualdefibrillator itis possibletoreducethepause betweenstoppingandrestartingofchestcompressionstoless thanfiveseconds.
• Continueresuscitationuntiltheresuscitationteamarrivesorthe patientshowssignsoflife.Followthevoicepromptsifusingan AED.
• Onceresuscitationisunderway,andiftherearesufficientstaff present,prepareintravenouscannulaeanddrugslikelytobeused bytheresuscitationteam(e.g.adrenaline).
• Identify one person to be responsible for handover to the resuscitation team leader. Use a structured communication toolforhandover (e.g.SBAR,RSVP).178,179Locatethepatient’s records.
• The quality of chest compressions during in-hospital CPR is frequentlysub-optimal.180,181Theimportanceofuninterrupted chestcompressionscannotbeoveremphasised.Evenshort inter-ruptionstochestcompressionsaredisastrousforoutcomeand everyeffortmustbemadetoensurethatcontinuous,effective chestcompressionis maintainedthroughouttheresuscitation attempt.Chestcompressionsshouldcommenceatthebeginning of a resuscitationattempt and continue uninterrupted unless theyarepausedbrieflyforaspecificintervention(e.g.rhythm
check).Mostinterventionscanbeperformedwithout interrup-tionstochestcompressions.Theteamleadershouldmonitorthe qualityofCPRandalternateCPRprovidersifthequalityofCPRis poor.
• ContinuousEtCO2monitoringduringCPRcanbeusedtoindicate
thequalityofCPR,andariseinEtCO2canbeanindicatorofROSC
duringchestcompressions.174,182–184
• Ifpossible,thepersonprovidingchestcompressionsshouldbe changedevery2min,butwithoutpausesinchestcompressions. ALStreatmentalgorithm
AlthoughtheALScardiacarrestalgorithm(Fig.1.7)isapplicable toallcardiacarrests,additionalinterventionsmaybeindicatedfor cardiacarrestcausedbyspecialcircumstances(seeSection4).3
Theinterventionsthatunquestionablycontributetoimproved survival aftercardiacarrestare promptand effectivebystander basiclife support(BLS), uninterrupted, high-qualitychest com-pressionsandearlydefibrillationforVF/pVT.Theuseofadrenaline hasbeenshowntoincreaseROSCbutnotsurvival todischarge. Furthermore there is a possibility that it causes worse long-term neurological survival. Similarly, the evidence to support the use of advanced airway interventions during ALS remains limited.175,185–192Thus,althoughdrugsandadvancedairwaysare still included among ALS interventions, they are of secondary importancetoearlydefibrillationandhigh-quality,uninterrupted chestcompressions.
Aswithpreviousguidelines,theALSalgorithmdistinguishes between shockable and non-shockable rhythms. Each cycle is broadlysimilar,withatotal of2minofCPR beinggiven before assessing the rhythm and where indicated, feeling for a pulse. Adrenaline1mgisinjectedevery3–5minuntilROSCisachieved –thetimingoftheinitialdoseofadrenalineisdescribedbelow. InVF/pVT,asingledoseofamiodarone300mgisindicatedaftera totalofthreeshocksandafurtherdoseof150mgcanbe consid-eredafterfiveshocks.TheoptimalCPRcycletimeisnotknownand algorithmsforlongercycles(3min)existwhichincludedifferent timingsforadrenalinedoses.193
Shockablerhythms(ventricularfibrillation/pulselessventricular tachycardia)
Havingconfirmedcardiacarrest,summonhelp(includingthe request for a defibrillator) and start CPR, beginning withchest compressions,withacompression:ventilation(CV)ratioof30:2. Whenthedefibrillatorarrives,continuechestcompressionswhile applyingthedefibrillationelectrodes.Identifytherhythmandtreat accordingtotheALSalgorithm.
• IfVF/pVTis confirmed,charge thedefibrillator whileanother rescuercontinueschestcompressions.Oncethedefibrillatoris charged,pausethechestcompressions,quicklyensurethatall rescuersareclearofthepatientandthengiveoneshock. • Defibrillationshockenergylevelsareunchangedfromthe2010
guidelines.194Forbiphasicwaveforms,useaninitialshockenergy ofatleast150J.Withmanualdefibrillatorsitisappropriateto considerescalating theshock energyif feasible,aftera failed shockandforpatientswhererefibrillationoccurs.195,196 • Minimisethedelaybetweenstoppingchestcompressionsand
deliveryoftheshock(thepreshockpause);evena5–10sdelay willreducethechancesoftheshockbeingsuccessful.84,85,197,198 • Withoutpausingtoreassesstherhythmorfeelforapulse,resume CPR(CVratio30:2)immediatelyaftertheshock,startingwith chestcompressionstolimitthepost-shockpauseandthetotal peri-shockpause.84,85
• ContinueCPRfor2min,thenpausebrieflytoassesstherhythm; ifstillVF/pVT,giveasecondshock(150–360Jbiphasic).Without
pausingtoreassesstherhythmorfeelforapulse,resumeCPR (CVratio30:2)immediatelyaftertheshock,startingwithchest compressions.
• ContinueCPRfor2min,thenpausebrieflytoassesstherhythm; ifstillVF/pVT,giveathirdshock(150–360Jbiphasic).Without reassessingtherhythmorfeelingforapulse,resumeCPR(CV ratio30:2)immediatelyaftertheshock,startingwithchest com-pressions.
• IfIV/IOaccesshasbeenobtained,duringthenext2minofCPR giveadrenaline1mgandamiodarone300mg.199
• The use of waveform capnography may enable ROSC to be detectedwithoutpausingchestcompressionsandmaybeused asawayofavoidingabolusinjectionofadrenalineafterROSChas beenachieved.Severalhumanstudieshaveshownthatthereisa significantincreaseinEtCO2whenROSCoccurs.174,182–184,200,201
If ROSC is suspected during CPR withhold adrenaline. Give adrenalineifcardiacarrestisconfirmedatthenextrhythmcheck. • IfROSChasnotbeenachievedwiththis3rdshock,theadrenaline mayimprovemyocardialbloodflowandincreasethechanceof successfuldefibrillationwiththenextshock.
• Timing of adrenaline dosing can cause confusion amongst ALSprovidersandthis aspectneedstobeemphasisedduring training.202 Trainingshouldemphasisethatgivingdrugsmust notleadtointerruptionsinCPRanddelayinterventionssuchas defibrillation.Humandatasuggestsdrugscanbegivenwithout affectingthequalityofCPR.186
• Aftereach2-mincycleofCPR,iftherhythmchangestoasystole orPEA,see‘non-shockablerhythms’below.Ifanon-shockable rhythmispresentandtherhythmisorganised(complexesappear regularornarrow),trytofeelapulse.Ensurethatrhythmchecks arebrief,andpulsechecksareundertakenonlyifanorganised rhythm isobserved. Ifthere is anydoubtaboutthepresence ofapulseinthepresenceofanorganisedrhythm,immediately resumeCPR.IfROSChasbeenachieved,beginpost-resuscitation care.
DuringtreatmentofVF/pVT,healthcareprovidersmustpractice efficientcoordinationbetweenCPR andshockdeliverywhether usingamanualdefibrillatororanAED.Reductionintheperi-shock pause (the interval between stopping compressions to resum-ing compressions after shock delivery) by even a few seconds can increase the probability of shock success.84,85,197,198 High-qualityCPRmayimprovetheamplitudeandfrequencyoftheVF andimprovethechanceofsuccessfuldefibrillationtoaperfusing rhythm.203–205
Regardlessofthearrestrhythm,aftertheinitialadrenalinedose hasbeengiven,givefurtherdosesofadrenaline1mgevery3–5min untilROSCisachieved;inpractice,thiswillbeaboutonceeverytwo cyclesofthealgorithm.IfsignsoflifereturnduringCPR(purposeful movement,normalbreathingorcoughing),orthereisanincreasein EtCO2,checkthemonitor;ifanorganisedrhythmispresent,check
forapulse.Ifapulseispalpable,startpost-resuscitationcare.Ifno pulseispresent,continueCPR.
Witnessed,monitoredVF/pVT. Ifapatienthasamonitoredand wit-nessedcardiacarrestinthecatheterlaboratory,coronarycareunit, acriticalcareareaorwhilstmonitoredaftercardiacsurgery,anda manualdefibrillatorisrapidlyavailable:
• Confirmcardiacarrestandshoutforhelp.
• IftheinitialrhythmisVF/pVT,giveuptothreequicksuccessive (stacked)shocks.
• Rapidlycheckforarhythmchangeand,ifappropriate,ROSCafter eachdefibrillationattempt.
• StartchestcompressionsandcontinueCPRfor2minifthethird shockisunsuccessful.
Fig.1.7.AdvancedLifeSupportalgorithm.CPR–cardiopulmonaryresuscitation;VF/PulselessVT–ventricularfibrillation/pulselessventriculartachycardia;PEA–pulseless electricalactivity;ABCDE–Airway,BreathingCirculation,Disability,Exposure;SaO2–oxygensaturation;PaCO2–partialpressurecarbondioxideinarterialblood;ECG– electrocardiogram.