Recommendation for Basic Life Support NRC Guideline Conference 2011 Lim Swee Han

MBBS (NUS), FRCS Ed (A&E), FAMS

Senior Consultant, Department of Emergency Medicine, Singapore General Hospital Clinical Associate Professor, Yong Loo Lin School of Medicine, National University of Singapore Co Chair Airway and CPR Adjunct, Member ALS Taskforce, ILCOR Honorary Secretary, Resusciation Council of Asia Chairman, BCLS Subcommittee, National Resuscitation Council, Singapore

BCLS Guidelines 2011

by NRC BCLS Subcommittee
Ng Ah Chee, AMK-THKH Goh Teck Koon, CGH Asmah Md Noor, NYP Chew Jenny, NYP Ho Soo Kim, IMH Ler Ai Choo, ITE Koh Gek Chee, KKWCH Tan Siew King, KTPH Shree Devi Gopal, NAP Ismail Sheriff, NHC Suresh Pillai, NUH Lew Michelle, RCHMC Kamsani, SCDF Lim Swee Han, SGH (Chair) Tan Boon Seng, SGH/Parkway College Fong Celestine, SMA Osman, SMM Chee Tek Siong, St Johns Ambulance Association Wee Fong Chi, TTSH

BCLS
Recognition of Sudden Cardiac Arrest Call for help, activation of emergency
response system

Maintaining airway patency, supporting breathing and the circulation without the use of equipment other than personal protective devices

Goals of CPR Training:

Participants can do and will do CPR

Evidence based Resuscitation Guideline Simplification

Highlights of changes in BCLS guidelines since 2005

Recognition of cardiac arrest Sequence of CPR Technique of chest compression
Landmark for chest compression Rate and depth of chest compression

SENSIVITIY, SPECIFICITY, AND RELIABILITY OF PULSE CHECK: PERFORMANCE OF PULSE CHECK AS A DIAGNOSTIC TEST
Pulse is Present Rescuer thinks pulse is present 81 (Sensitivity: correct positive result of pulse check all times a pulse was actually present) a 66 Pulse is Absent 6 Totals 87 (No. of times rescuer thought pulse present=a + b)

b 53 (Specificity: correct negative result of pulse check all times there actually was no pulse) 119
(No. of times rescuer thought pulse absent= c +d)

Rescuer thinks pulse is absent

c Totals 147 (Total number of study opportunities where a pulse was actually present= a + c)

d 59 (Total number of study opportunities where a pulse was actually absent= b + d) 206 (total study opportunities= a + b + c +d)

Pulse check trained ( using appropriate mannikin) healthcare provider

Phoenix Fire Department An analysis of 1218 EMS-attended, witnessed, OHCA Presumed cardiac origin
Presence of gasping (%)

39/119 (33%) 73/363 (20%)

50/360 (14%)

25/338 (7%)

(EMS arrival time)

Bobrow, JAMA, 2008

Survival to Hospital Discharge

Gasped 54/191 (28%) Those received bystander CPR No Gasp 80/1027 (8%) Adjusted OR, 95% CI 3.4, 95% CI, 2.2 to 5.2

30/77 (39%)

38/404 (9%)

5.1, 95% CI, 2.7 to 9.4

Recognition of Gaspining is NOT normal breathing

Bobrow, JAMA, 2008

16 secs

42%

58%

bsCPR 36%

bsCPR 22%

Hpfl M, Lancet 2010

NEJM

NEJM NEJM

Hpfl M, Lancet 2010

Percentage of 5170 Patients Aged 1 to 17 Surviving Neurologically Intact for 1 month Postarrest
Origin No CPR (n=2719 Bystander CPR (n=2439) CPR vs Compression- Conventional Conventional no CPR, only CPR CPR(n=1551) CPR vs odds compression(n=888) ratio only, odds (95% CI) ratio (95% CI) 4.17 (2.37-7. 32) 1.6 7.2 5.54 (2.52-16.99)

Noncardiac 1.5 (n=3675)

5.1

Cardiac (n=1495)

4.1

9.5

2.21 (1.08-4. 54

8.9

9.9

1.2 (0.55-2.66)

Kitamura, Lancet 2010

Victim
Adult
VF Arrest / Cardiac cause Respond time < 5 min

Victim
Adult
Asphyxia (non cardiac cause) drowning, trauma, intoxication Cardiac arrest 15 min

Rescuer
Untrained Unable (or unwilling) to perform mouth to mouth effectively, without long interruption of chest compression

Children

Rescuer
Able and willing to perform mouth to mouth (effective)

Chest-compression only CPR

Chest compression and mouth to mouth ventilation

Quality of CPR During InHospital Cardiac Arrest

Case series n=67 (Chicago) Outcome measure = G2000 standards Chest compressions were too slow 38% of the compressions were too shallow Ventilation rates were too high

ONE-MAN CPR STRIP INTERPRETATION

400 600 m/s 1 sec

6 sec

18 sec (at least 100 min)

5cm

>100

>5

mouth

Kouwenhoven et al. JAMA 1960

Locate landmark for chest compression

Hand Position for Chest Compression

S Kusunoki et al Resuscitation 80(2009)

 One hundred Japanese patients 12 male and 6 female anaesthsiologists D value was positive in 51 patients, no significant diff between the genders For 5 (10%) of the female patients, the heel of the rescuer extended beyond the xiphoid process to the epigastric region. This only happened to the females No significant correlation between D vale and patient age, height, weight and BMI

S Kusunoki et al Resuscitation 80(2009)

Intrathoraic structure beneath the inter-nipple line 80% was a structure just cephalad to theLV ie ascending aorta, root of the aorta, or the left ventricular outflow tract

J Shin et al Resuscitation 75 (2007)

Adult Basic Life Support

CHECK DANGER UNRESPONSIVE? TAP SHOULDER FIRMLY ASK LOUDLY ACTIVATE EMERGENCY RESPONSE SYSTEM GET AED OPEN AIRWAY HEAD TILT, CHIN LIFT CHECK PULSES FOR HEALTHCARE PROVIDER ONLY DEFINE PULSE AND NORMAL BREATHING WITHIN 10 SEC

NOT BREATHING NORMALLY? LOOK, LISTEN, FEEL 10 SEC

30 CHEST COMPRESSIONS CENTRE OF CHEST / LOWER HALF OF STERNUM DEPTH AT LEAST 5 CM RATE AT LEAST 100 PER MIN ALLOW COMPLETE CHEST RECOIL OPEN AIRWAY HEAD TILT, CHIN LIFT

2 BREATHS 1 SEC PER BREATH TIDAL VOLUME 500-600 CHEST RISE

RECHECK VICTIM ONLY ( IF HE STARTS TO WAKE UP/ MOVE / OPEN EYES / BREATH NORMALLY OR EXPERT HELP / DEFIBRILLATOR ARRIVES)

DO A GREAT QUALITY CHEST COMPRESSIONS AT 100 / MINUTE, IF UNABLE / UNWILLING TO VENTILATE FOR ANY REASON

CPR Sequence Establish Unresponsiveness Call 995, get AED Open Airway Recognition of Cardiac Arrest Pulse Check (for Trained Healthcare Providers Only) Start Chest Compressions Compression Landmarks Compression Method Compression Depth Compression Rate Compression : Ventilation Ratio Breathing

Adult and Older Child Immediately

Child (1-8 Years of Age)

Infant (Less than 1 Year of Age)

After 2 minutes CPR Head Tilt Chin Lift

Check for normal breathing (gasping is not normal breathing) Carotid Brachial

If no normal breathing or pulse check (by trained healthcare providers only) within 10 seconds Lower half of sternum Heel of 1 hand, other on top At least 5 cm 5 cm At least 100 / minutes 30:2 (1 or 2 rescuers) 2 breaths at 1 second per breath. The two breaths should not take more than 6 seconds. Lower half of sternum (Just below intermammary line) 2 Fingers 4 cm

ONE-MAN CPR STRIP INTERPRETATION

400 600 m/s 1 sec

6 sec < 130 sec

18 sec

Passing Criteria: 1) NOT MORE THAN 30 Compressions & 5 Ventilations mistakes are allowed 2) IMMEDIATE FAILURE for wrong landmark location for chest compressions i.e. outside the sternum (Exclamation mark appearing but correct hand position -> ignore

Chest compression only CPR

Compression only CPR is instructed during dispatcher CPR Rescuers are unable or unwilling to provide mouth to mouth ventilations should be encouraged to perform good chest compressions

2-men CPR
One of the rescuers to call 995 for activation of emergency response system and get AED once the victim is found to be unresponsive. The other is to continue to check for breathing (and pulse for trained healthcare providers only) and to start on chest compressions when needed. Rescuers should take turns to perform CPR every 2 min (5 cycles, 30 chest compressions : 2 ventilations) *
* Minimal interruption for chest compressions

FBAO

Abdominal Thrust / Heimlich Manoeuvre

Chest Thrusts

Optional module for NRC BCLS course