Introduction

This chapter contains the guidelines for out-of-hospital, single rescuer, adult basic life support (BLS). Like the other guidelines in this publication, it is based on the document 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations (CoSTR), which was published in October 2010. Basic life support refers to maintaining airway patency and supporting breathing and the circulation without the use of equipment other than aprotective device. It is important that those who may be present at the scene of a cardiac arrest, particularly lay bystanders, should have learnt the appropriate resuscitation skills and be able to put them into practice. Simplification of the BLS sequence continues to be a feature of these guidelines, but, in addition, there is now advice on who should be taught what skills, particularly chest-compression-only or chest compression and ventilation. Within this advice, allowance has been made for the rescuer who is unable or unwilling to perform rescue breathing, and for those who are untrained and receive

telephone advice from the ambulance service. Guidelines 2000 introduced the concept of checking for ‘signs of a circulation’. This change was made because of the evidence that relying on a check of the carotid pulse to diagnose cardiac arrest is unreliable and time-consuming, mainly, but not exclusively, when attempted by non-healthcare professionals.9 Subsequent studies have shown that checking for breathing is also prone to error, particularly as agonal gasps are often misdiagnosed as normal breathing.10 In Guidelines 2010 the absence of normal

breathing continues to be the main sign of cardiac arrest in a non-responsive victim. Once cardiopulmonary resuscitation (CPR) has started, it is now recommended that the rescuer should only stop CPR if the victim shows signs of regaining consciousness, such as coughing, opening his eyes, speaking, or moving purposefully, as well as breathing normally.

Guideline changes

It is well documented that interruptions in chest compression are common11, 12 and are associated with a reduced chance of survival.13 The ‘perfect’ solution is to deliver continuous compressions whilst giving ventilations independently. This is possible when the victim has an advanced airway in place, and is discussed in the adult advanced life support (ALS) chapter. Compression-only CPR is another way to increase the number of compressions given and will, by definition, eliminate pauses. It is effective for a limited period only (probably less than 5 min)14 and is not recommended as the standard management of out-of-hospital cardiac arrest.

It is also known that chest compressions, both in hospital and outside, are often undertaken with insufficient depth and at the wrong rate.12, 15 The following changes in the BLS guidelines have been made to reflect the importance placed on chest compression, particularly good quality compressions, and to attempt to reduce the number and duration of pauses in chest compression:

1. When obtaining help, ask for an automated external defibrillator (AED), if

one is available.

2. Compress the chest to a depth of 5-6 cm and at a rate of 100-120 min-1.

3. Give each rescue breath over 1 s rather than 2 s.

4. Do not stop to check the victim or discontinue CPR unless the victim starts to

show signs of regaining consciousness, such as coughing, opening his eyes,

speaking, or moving purposefully AND starts to breathe normally.

5. Teach CPR to laypeople with an emphasis on chest compression, but include ventilation as the standard, particularly for those with a duty of care. In addition, advice has been added on the use of oxygen, and how to manage a victim who regurgitates stomach contents during resuscitation.

Adult basic life support algorithm

UNRESPONSIVE ?

Shout for help

Open airway

NOT BREATHING NORMALLY ?

Call 999

30 chest Compressions

2 rescue breaths :30 compressions

Adult basic life support sequence

Basic life support consists of the following sequence of actions:

1. Make sure the victim, any bystanders, and you are safe.

2. Check the victim for a response.

 Gently shake his shoulders and ask loudly, ‘Are you all right?’

3A. If he responds:

 Leave him in the position in which you find him provided there is no further

danger.

 Try to find out what is wrong with him and get help if needed.

 Reassess him regularly.

3B. If he does not respond:

 Shout for help.

 Turn the victim onto his back and then open the airway using head tilt and

chin lift:

o Place your hand on his forehead and gently tilt his head back.

o With your fingertips under the point of the victim's chin, lift the chin

to open the airway.

4. Keeping the airway open, look, listen, and feel for normal breathing.

 Look for chest movement.

 Listen at the victim's mouth for breath sounds.

 Feel for air on your cheek.

In the first few minutes after cardiac arrest, a victim may be barely breathing, or taking

infrequent, noisy, gasps. This is often termed agonal breathing and must not be

confused with normal breathing.

Look, listen, and feel for no more than 10 s to determine if the victim is breathing

normally. If you have any doubt whether breathing is normal, act as if it is not normal.

5A. If he is breathing normally:

 Turn him into the recovery position (see below).

 Summon help from the ambulance service by mobile phone. If this is not

possible, send a bystander. Leave the victim only if no other way of obtaining

help is possible.

 Continue to assess that breathing remains normal. If there is any doubt

about the presence of normal breathing, start CPR (5B).

Resuscitation Council (UK)

5B. If he is not breathing normally:

 Ask someone to call for an ambulance and bring an AED if available. If you

are on your own, use your mobile phone to call for an ambulance. Leave the

victim only when no other option exists for getting help.

 Start chest compression as follows:

o Kneel by the side of the victim.

o Place the heel of one hand in the centre of the victim’s chest

(which is the lower half of the victim’s sternum (breastbone)).

o Place the heel of your other hand on top of the first hand.

o Interlock the fingers of your hands and ensure that pressure is not

applied over the victim's ribs. Do not apply any pressure over the

upper abdomen or the bottom end of the sternum.

o Position yourself vertically above the victim's chest and, with your

arms straight, press down on the sternum 5 - 6 cm.

o After each compression, release all the pressure on the chest

without losing contact between your hands and the sternum.

Repeat at a rate of 100 - 120 min-1.

o Compression and release should take an equal amount of time.

6A. Combine chest compression with rescue breaths:

 After 30 compressions open the airway again using head tilt and chin lift.

 Pinch the soft part of the victim’s nose closed, using the index finger and

thumb of your hand on his forehead.

 Allow his mouth to open, but maintain chin lift.

 Take a normal breath and place your lips around his mouth, making sure

that you have a good seal.

 Blow steadily into his mouth whilst watching for his chest to rise; take about

one second to make his chest rise as in normal breathing; this is an effective

rescue breath.

 Maintaining head tilt and chin lift, take your mouth away from the victim and

watch for his chest to fall as air comes out.

 Take another normal breath and blow into the victim’s mouth once more to

give a total of two effective rescue breaths. The two breaths should not take

more than 5 s. Then return your hands without delay to the correct position

on the sternum and give a further 30 chest compressions.

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

 Stop to recheck the victim only if he starts to show signs of regaining

consciousness, such as coughing, opening his eyes, speaking, or moving

purposefully AND starts to breathe normally; otherwise do not interrupt

resuscitation.

Resuscitation Council (UK)

20 RESUSCITATION GUIDELI NE S 2010

If the initial rescue breath of each sequence does not make the chest rise as in normal

breathing, then, before your next attempt:

 Check the victim's mouth and remove any visible obstruction.

 Recheck that there is adequate head tilt and chin lift.

 Do not attempt more than two breaths each time before returning to chest

compressions.

If there is more than one rescuer present, another should take over CPR about every

1-2 min to prevent fatigue. Ensure the minimum of delay during the changeover of

rescuers, and do not interrupt chest compressions.

6B. Compression-only CPR

 If you are not trained to, or are unwilling to give rescue breaths, give chest

compressions only.

 If chest compressions only are given, these should be continuous at a rate of

100 - 120 min-1.

 Stop to recheck the victim only if he starts to show signs of regaining

consciousness, such as coughing, opening his eyes, speaking, or moving

purposefully AND starts to breathe normally; otherwise do not interrupt

resuscitation.

7. Continue resuscitation until:

 qualified help arrives and takes over,

 the victim starts to show signs of regaining consciousness, such as

coughing, opening his eyes, speaking, or moving purposefully AND starts to

breathe normally, OR

 you become exhausted.