Basic life support for health care providers--new resuscitation guidelines for adults and children.

When a patient suddenly collapses and stops breathing, that person's fate is determined solely by the actions of the nearest bystanders, whether they be health care professionals or lay witnesses. Unless immediate steps are taken to commence effective resuscitation, irreversible brain damage and death will result within approximately 4-8 minutes. A systematic approach is provided, based on the latest international recommendations, (1) as a guide to the initial management of a cardiac arrest victim.

H-Hazards?

* Ensure that it is safe to approach the patient.

* Take universal precautions; put on gloves.

* Have a barrier device ready (e.g. protective mouthpiece or bag-valve-mask if available).

H-Hello?

* Tap and/shout 'hello' to determine if the patient is responsive.

* If responsive, treat illnesses or injuries as necessary and get assistance. if needed; reassess patient continuously.

* If unresponsive, shout for help. H-Help!

* Call for assistance.

* Send someone to fetch a manual defibrillator or automated external defibrillator (AED) immediately.

A--Airway

* If you do not suspect a neck or spinal injury, open the airway by tilting the head back with one hand and lifting the chin upwards with the other hand (head tilt-chin lift manoeuvre) to prevent the tongue blocking the airway.

* If you suspect a neck or spinal injury, rather attempt a jaw thrust (if 2 rescuers are present) or just a chin lift (if you are alone) if possible.

* Open the mouth and remove any visible foreign material.

* If there is vomitus, turn the patient onto his/her side to clear the mouth; use a suction device if immediately available.

* Place your ear next to the patient's mouth and look, listen and feel for adequate breathing for up to 10 seconds.

B--Breathing

* If the patient is breathing adequately (more than the occasional gasp), place the patient into the recovery position by rolling the patient onto his/her side. Watch for continued breathing and reassess continuously.

* If the patient is not breathing, or not breathing adequately (e.g. gasping), give 2 effective breaths, preferably using a protective mouthpiece or bag-valve-mask (with 100% oxygen) if available.

* Allow 1 second for each breath.

* Ensure that the chest rises with each breath. If not, reposition the patient's head and your mouth or the mask to get a better seal.

* Feel for a pulse for up to 10 seconds (check for the presence of a carotid pulse in an adult or child; check for a brachial pulse in an infant) (Fig. 1).

* If a definite pulse is felt but the patient is not breathing adequately, continue giving rescue breaths at a rate of 10/ minute for adults and 12-20/minute for children.

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C--Circulation

* If a definite pulse is not felt within 10 seconds, or if you are not sure if a pulse is present, start chest compressions.

* With the patient on a firm flat surface, kneel at the side of the patient with your knees slightly apart.

* Expose the chest and place one hand on the sternum in the middle of the chest, in the midline in line with the nipples.

* Place the second hand over the first, interlocking and raising your fingers so that only the heel of one hand is resting on the sternum (Fig. 2).

* With your shoulders directly above the patient's chest and your arms straight and elbows 'locked', press firmly down on the chest 30 times at a rate of 100 compressions per minute (almost 2 compressions per second). Ensure full chest recoil between each compression.

* If the patient is an adult (post-puberty), compress to a depth of 4-5 cm using both hands. Push hard and push fast.

* If the patient is a child (pre-pubertal), compress to a depth of 1/3-1/2 the diameter of the chest wall. Use either 1 or 2 hands, depending on the size of the patient and the strength of the rescuer.

* If the patient is an infant (less than 1 year old), place 2 or 3 fingers just below an imaginary line drawn between the infant's nipples, and compress down 1/3-1/2 the diameter of the chest (Fig. 3).

* After 30 chest compressions, give 2 breaths.

* Continue cycles of 30:2, without interruptions, until help arrives or the patient recovers.

* When a second competent rescuer becomes available, switch the compressor role after every 5 cycles (approximately every 2 minutes) as rescuers will tire very quickly. Do not take any longer than 5 seconds to swap places.

* For children and infants, when a second competent rescuer becomes available, provide cycles of 15 compressions followed by 2 breaths.

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Cricoid pressure (Sellick's manoeuvre)

If there are 2 or more rescuers, 1 rescuer may provide pressure on the cricoid cartilage (Sellick's manoeuvre) to prevent air entering the stomach and regurgitation of gastric contents with subsequent pulmonary aspiration.

First locate the thyroid cartilage (Adam's apple) with thumb and index finger, then slide your fingers inferiorly until you feel another smaller cartilage below (the cricoid cartilage). Using the tips of the thumb and the index finger, press firmly down on the cricoid cartilage, compressing the oesophagus.

D--defibrillation

* Continue cycles of compressions and ventilations, without interruptions, until a manual defibrillator or AED becomes available and is switched on and ready for use.

* Immediately place paddles or pads on the patient's bare chest and analyse the rhythm.

* If the rhythm is shockable (ventricular fibrillation or pulseless ventricular tachycardia), deliver one shock and immediately resume CPR for 2 minutes:

* if using a monophasic (older) defibrillator, use 360 Joules

* if using a biphasic (newer) defibrillator, use between 120 and 360 Joules, depending on the recommendations of the specific manufacturer

* if defibrillating a child, use 4 Joules/ kg, irrespective of the make and age of defibrillator.

* Repeat the shock after every 2 minutes of CPR if the rhythm remains shockable (VF/VT).

* If the rhythm is found to be nonshockable (pulseless electrical activity or asystole), immediately resume CPR for 2 minutes, then reanalyse the rhythm. If organised electrical activity returns (identifiable QRS complexes), check for the return of a pulse for 10 seconds. If a definite pulse is felt, check for breathing and commence post-resuscitation care.

* If the pulse is absent or the rhythm is asystole, immediately resume CPR for another 2 minutes before reanalysing the rhythm again.

E--Endotracheal intubation 

* Protection of the airway using an invasive airway device such as an endotracheal tube (ETT), laryngeal mask airway (LMA) or tracheo-oesophageal combitube (TOC) can be done when rescuers with the necessary skills, expertise and equipment become available.

* Once the patient has an invasive airway device in place (ETT, LMA or TOC), chest compressions are performed continuously at a rate of 100/minute, with no pause in compressions for the delivery of breaths.

* Ventilations are given every 6-8 seconds (approximately 8-10 ventilations/min) while chest compressions continue uninterrupted.

* High-quality, continuous compressions will be tiring. It is recommended that the rescuers doing ventilations and compressions swop tasks every 2 minutes, while the rhythm is being analysed. Ensure that the interruption takes no more than 10 seconds.

Conclusion

A systematic approach, using an alphabetical sequence and supported by an algorithm endorsed by the Resuscitation Council of Southern Africa and the Emergency Medicine Society of South Africa, is provided as a memory aid for the immediate management of a sudden unexpected collapse of a victim in respiratory or cardiac arrest (Fig. 4). The mortality and morbidity of that patient is determined by the actions taken by the nearest rescuer within the subsequent few minutes--every second counts!

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Recommended Reading

International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2005; 67(2-3): 157-314.

WALTER KLOECK, MB BCh, FCEM (SA), Dip PEC (SA)

Chairman, Resuscitation Council of Southern Africa, Johannesburg

ANNE MILLUM, N Dip AEC, HED, N Dip Adult Education, MSc

Principal, EMS Academy