Emergency medicine - Always be prepared to give resuscitation

Resuscitation is different outside the hospital environment, explain Dr Jon Dallimore and Professor Jonathan Benger.

Photograph: solent news
Photograph: solent news

Management of cardiac arrest in the community or the surgery is very different to the management in a fully-staffed emergency department or hospital ward.

Often the GP will be faced with a collapsed patient in an awkward position, a small amount of equipment and limited assistance until an ambulance arrives.

Resuscitation guidelines
Resuscitation guidelines were updated in 2005 with the aim of improving long-term survival.

Following the 2005 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations, two very important changes were recommended:

1. The need to maintain effective chest compressions with minimal interruption.

2. The importance of simplifying guidelines to make them easier to learn and to remember.

There were also other important changes. Rescuers should place their hands 'in the centre of the chest' rather than trying to find landmarks on the patient's chest.

Give 30 compressions immediately after cardiac arrest is diagnosed and omit the two rescue breaths previously recommended.

Use a ratio of compressions to ventilations of 30:2 for all adult cardiac arrest patients.

Rescue breaths should be given over one second rather than two seconds.

Chest compressions alone are acceptable if a rescuer is reluctant to give rescue breaths - it is effective for a limited period (about five minutes).

Where possible, another person should take over the compressions every two minutes because it is very tiring. This may not be possible if the GP is the only person available until the arrival of further help.

Minimise interruptions in chest compressions - this helps to maintain a small but significant blood supply to the brain.

Basic life support
Basic life support is the maintenance of an open airway, breathing and circulation without the use of equipment apart from a protective device such as a face shield. The combination of rescue breathing and chest compression is known as cardiopulmonary resuscitation (CPR). This provides a small amount of blood flow to the brain and heart.

Survival from cardiac arrest is most likely when the event is witnessed, when CPR is started immediately, and when defibrillation and advanced life support are instituted at an early stage - the chain of survival.

Shake the victim's shoulders and ask loudly 'Are you alright?'

If the person does not respond, shout for help, turn them onto their back and open the airway using head tilt and chin lift.

Keeping the airway open, look for chest movements, listen for breath sounds and feel for air movement on your cheek. Take no more than 10 seconds to check breathing.

Early CPR
If the patient is not breathing normally, start chest compressions: kneel by the patient and place your hands in the centre of their chest.

Position yourself vertically above the chest and press down on the sternum 4-5cm, keeping your arms straight while doing this.

Give 30 compressions at a rate of about 100 times a minute (compression and release should take an equal amount of time). After 30 compressions open the airway using head tilt and chin lift.

Pinch the patient's nose closed and allow the mouth to open, but maintain chin lift.

Take a normal breath and blow steadily into the mouth while watching for chest rise; allow about one second of chest rise, as in normal breathing.

Take another normal breath and blow into the patient's mouth once more to give a total of two effective rescue breaths. Then give a further 30 chest compressions.

Continue with chest compressions and rescue breaths in a ratio of 30:2. Stop to recheck the patient only if they start breathing normally.

If rescue breaths do not make the chest rise, then before your next attempt check the patient's mouth and remove any visible obstruction and recheck that there is adequate head tilt and chin lift.

Early defibrillation
Many GPs have an automated external defibrillator (AED) available in their surgeries. It is essential that practice staff are familiar with the location and use of this device, and that it is properly maintained.

Before using the AED make sure that you, the patient and any bystanders are safe. Check for level of response and normal breathing (as above).

If the patient is unresponsive and not breathing normally, send for the AED and call 999.

Commence immediate CPR and when the defibrillator arrives, switch it on and attach the pads. If more than one person is available continue CPR.

Follow the spoken/visual directions from the AED. Do not allow anyone to touch the patient during rhythm analysis.

If a shock is indicated ensure that nobody touches the patient and press the shock button as directed. When directed, continue CPR without delay. If no shock is indicated, immediately recommence CPR to minimise delays in chest compressions.

Post resuscitation care
If attempts at resuscitation are successful and the patient develops spontaneous breathing or has a palpable pulse, if possible document oxygen saturations, pulse rate, BP and respiration rate.

Consider a 12-lead ECG if practicable. Transfer the patient to hospital for further management.

  • Dr Dallimore is a GP and staff grade in emergency medicine, Bristol Royal Infirmary and Professor Benger is professor of emergency care, University of the West of England, consultant in emergency medicine, University Hospitals Bristol NHS Foundation Trust and, medical advisor, air operations, Great Western Ambulance Service
  • This topic falls under section 7 of the GP curriculum, 'Care of Acutely Ill People', www.rcgp-curriculum.org.uk

ADULT BLS ALGORITHM

  • Unresponsive
  • Shout for help
  • Open airway
  • Not breathing normally?
  • Call 999
  • 30 chest compressions
  • 2 rescue breaths
  • 30 chest compressions

Learning points

1. Give chest compressions and rescue breaths in a ratio of 30:2, with the chest compressions first.

2. Chest compressions must be maintained with minimal interruptions.

3. Ensure all practice staff are familiar with the use of an AED and know its location on the premises.

4. Have someone call an ambulance so the patient can be transferred to hospital for further treatment.

 

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