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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

1

aEmergencyMedicine,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

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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.

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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.

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• 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

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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

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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

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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

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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.

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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.

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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.

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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

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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

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• 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

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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.

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Fig.1.7.AdvancedLifeSupportalgorithm.CPR–cardiopulmonaryresuscitation;VF/PulselessVT–ventricularfibrillation/pulselessventriculartachycardia;PEA–pulseless electricalactivity;ABCDE–Airway,BreathingCirculation,Disability,Exposure;SaO2–oxygensaturation;PaCO2–partialpressurecarbondioxideinarterialblood;ECG– electrocardiogram.

Figure

Fig. 1.2. The Chain of Survival.
Fig. 1.4. Step by step sequence of actions for use by the BLS/AED trained provider to treat the adult cardiac arrest victim.
Fig. 1.6. In-hospital resuscitation algorithm. ABCDE – Airway, Breathing Circulation, Disability, Exposure IV – intravenous; CPR – cardiopulmonary resuscitation.
Fig. 1.7. Advanced Life Support algorithm. CPR – cardiopulmonary resuscitation; VF/Pulseless VT – ventricular fibrillation/pulseless ventricular tachycardia; PEA – pulseless electrical activity; ABCDE – Airway, Breathing Circulation, Disability, Exposure; S
+7

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