Learn about the history and future of resuscitation (CPR)
Post - 7th July 2015
The common memory that people have of resuscitation (CPR) training is that it seemed to continually change. This is true and reflects one of the issues with CPR over the years in that it has suffered from the influence of unproven theory of how CPR works. While the concept is quite old, it was not really till late 2005 at the meeting of the International Liason Committee on Resuscitation (ILCOR) that the review of real evidence stabilised the frequent changes in CPR practice. There is still much to improve in CPR (particularly in Australia) where there is low understanding of CPR, poor availability of defibrillators in the community and basic CPR guidelines that fall short of international best-practice. In this discussion, I will try to avoid arguing about "percentage survival" as this definition as well as being subjective it is also not accurately known, particularly in Australia, where there is no centralised data for this analysis. What we do know is that a victim's heart stopping effective function is the worst thing that can happen to them and it probably won't ever start again, regardless of our best efforts. In adults, of the 33,000 victims of cardiac arrest each year, it is probably in the order of 5-10%, but probably closer to 5% overall. On a more positive note, we will look at which measures have shown an improvement in survival and which ones haven't.
So let's start our CPR journey in 1776 where the Royal Humane Society in England made recommendations about CPR that were both impractical and rather uncomfortable for the poor victim.
"It is necessary to immediately stimulate the vital factors reactivating the lungs and the intestines. Then air is blown directly into the mouth of the patient and tobacco fumes are injected into the anus, at the same time keeping the body warm through rubbing performed with hot cloths or salt, or flannel soaked in brandy or rum or other strong alcoholic or spirituous liqueurs; the sense of smell is stimulated by applying spirit of volatile salt or ammoniac in the nostrils, which must be smeared on the temples to stimulate the head nerves; both throat and nostrils are tickled with a feather to reactivate the functions of the digestive apparatus inducing vomit and sneezing."
Royal Humane Society 1776
Many techniques over the years have involved rocking and manipulating victims to stimulate their circulation or breathing. At one stage, the Ambulance in NSW used carbon dioxide to ventilate victims in cardiac arrest because the "latest thinking" was that CO2 would stimulate breathing.
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If we take our story to 1927, in the silent movie days, when a "breakthrough" in CPR was released by the United States Public Health Service that promised successful revival of a victim.
So after all these wacky theories, what changed in 2005 and led to changes in Australia in March 2006? Well ILCOR 2005 discovered three important things about CPR, that:
- Compressions to a victim's chest while the most important part of CPR, does not replicate the heart's function by pumping blood around the victim's body. Instead rather the pressure on the chest increases the pressure inside the chest and blood that is pooled in large vessels in the chest (including the heart chambers and the aorta which is the main large vessel coming out of the top of the heart). This pressure forces the blood in the heart and other vessels involved away from the chest. This means that much deeper and faster compressions where needed.
- The full effect of this pressure in compressions is not immediate and takes several compressions to establish, however once stopped, the blood movement stops almost instantaneously. This meant that compressions should be interrupted as little as possible.
- Compressions also result in "passive ventilation" i.e. the pressure forces some air out of the lungs and when released, air is drawn back into the lungs. When measured the amount of air forced in and out during this process is more than half the normal required amount for a conscious healthy victim (around 300-400ml in and adult). This meant that the victim was already receiving some good ventilation with just compressions. This also meant that ratios of compressions to ventilation could be increased to 30 compressions to 2 ventilations. However, at the next meeting of ILCOR in 2010 new evidence would recommend that is some instances ventilations could be omitted altogether.
CPR should not be difficult to learn. Even children have been able to achieve and retain a basic understanding of resuscitation with minimal training
One of the other, more fundamental things changing in CPR was the realisation that this was a technique that could be applied with very little training. Many organisations who had a vested interest in making CPR training seem complicated and costly resisted this change in attitude and understanding of CPR. This trend of simplifying CPR has continued and we will see that the least complicated techniques were actually the ones that made the real difference in survival.
Then at the ILCOR meeting of 2010 there was a surprise finding from research on arrests since 2005 which indicated that "in some circumstances the inclusion of ventilations in resuscitation attempts was producing worse outcomes". This news meant that the reduction in the emphasis on ventilations and the focus on compressions was showing that ventilations were in some circumstances even less important. From this central finding emerged two clear recommendations:
These findings resulted in a positive change in focus of bystander CPR in the US and Europe to the concept of "hands only" (compression only) CPR as the recommended method for bystander CPR and that ventilations are really only for emergency responders when they arrive. This change not only resulted in more people being willing to attempt CPR but meant that valuable time was not being wasted with measures that did not improve outcomes and focused the public on good compressions. Sadly in Australia these evidence-based recommendations (still to this day) had no effect on the ARC guidelines here. Some providers in Australia actually started training people with these new changes before the Australian Resuscitation Council (ARC) released their new guidelines, only to find that the new guidelines in Australia fell way short of best practice and stuck with the notion that ventilations for all victims and all rescuers was a good idea.
Since then in Australia outcomes from cardiac arrest have continued to fall. some reasons include the focus in Australia not shifting to "compressions only" for first responders, the failure to keep pace with other changes to increase the rate and depth of compression with the ARC deciding to stick with more conservative values. While this failure to show leadership seems inexplicable, there are other examples of where the ARC has failed to recommend change or gone against the international resuscitation community, but that's a discussion for another day.
Then at the ILCOR meeting of 2010 there was a surprise finding from research on arrests since 2005 which indicated that "in some circumstances the inclusion of ventilations in resuscitation attempts was producing worse outcomes". This news meant that the reduction in the emphasis on ventilations and the focus on compressions was showing that ventilations were in some circumstances even less important. From this central finding emerged two clear recommendations:
- In victims who suffered a Sudden Cardiac Arrest (SCA) which is the most common form of arrest, the inclusion of ventilations in the initial CPR actually led to slightly poorer outcomes.
- In victims who have suffered a Hypoxic Arrest (where there is a low availability of oxygen that leads to a cardiac arrest e.g. drownings, chokings, strangulations i.e. almost all cardiac arrests in children, the inclusion of ventilations in the initial resuscitation was beneficial.
These findings resulted in a positive change in focus of bystander CPR in the US and Europe to the concept of "hands only" (compression only) CPR as the recommended method for bystander CPR and that ventilations are really only for emergency responders when they arrive. This change not only resulted in more people being willing to attempt CPR but meant that valuable time was not being wasted with measures that did not improve outcomes and focused the public on good compressions. Sadly in Australia these evidence-based recommendations (still to this day) had no effect on the ARC guidelines here. Some providers in Australia actually started training people with these new changes before the Australian Resuscitation Council (ARC) released their new guidelines, only to find that the new guidelines in Australia fell way short of best practice and stuck with the notion that ventilations for all victims and all rescuers was a good idea.
Since then in Australia outcomes from cardiac arrest have continued to fall. some reasons include the focus in Australia not shifting to "compressions only" for first responders, the failure to keep pace with other changes to increase the rate and depth of compression with the ARC deciding to stick with more conservative values. While this failure to show leadership seems inexplicable, there are other examples of where the ARC has failed to recommend change or gone against the international resuscitation community, but that's a discussion for another day.
Post - 17th July 2015
So what are the current BLS recommendations in Australia and what should they look like if we are to improve outcomes in cardiac arrest?
The biggest single biggest improvement in survival that we can achieve i.e. <10% presently to up to 75% is if defibrillation is delivered within 3 minutes of the arrest with good compressions., The only way to achieve this target is to have a wider availability of AEDs in the community. This of course still relies on good compressions. The fact is that in the case of Sudden Cardiac Arrest (SCA), being the most common type of cardiac arrest worldwide, the only two measures that make any significant difference in the initial management are:
Good compressions - considering a UK study showed that less than 46% of the adult population including health professionals are able to achieve satisfactory chest depth, this is harder to do and sustain than most people think). We shall examine this issue later.
Early Defibrillation - if we are waiting for an Ambulance for this we will be disappointed. Average NSW Ambulance response times in metropolitan areas are around 9.3 minutes, well outside the ideal of less than 3 minutes. This Ambulance response time also assumes that the Ambulance was called at the very moment the patient had the cardiac arrest and the crew was already in their vehicle and the crew was able to use the defibrillator by jumping from the vehicle as it arrives and simultaneously placing the pads on the patient's chest and delivering a shock.
Despite, improvements in outcome around the world by getting first responders to focus on these two important measures, in Australia we sit at least 5 years behind in our guidelines on this. In Australia for BLS you would be familiar with the current chart as recommended by the ARC.
So what are the current BLS recommendations in Australia and what should they look like if we are to improve outcomes in cardiac arrest?
The biggest single biggest improvement in survival that we can achieve i.e. <10% presently to up to 75% is if defibrillation is delivered within 3 minutes of the arrest with good compressions., The only way to achieve this target is to have a wider availability of AEDs in the community. This of course still relies on good compressions. The fact is that in the case of Sudden Cardiac Arrest (SCA), being the most common type of cardiac arrest worldwide, the only two measures that make any significant difference in the initial management are:
Good compressions - considering a UK study showed that less than 46% of the adult population including health professionals are able to achieve satisfactory chest depth, this is harder to do and sustain than most people think). We shall examine this issue later.
Early Defibrillation - if we are waiting for an Ambulance for this we will be disappointed. Average NSW Ambulance response times in metropolitan areas are around 9.3 minutes, well outside the ideal of less than 3 minutes. This Ambulance response time also assumes that the Ambulance was called at the very moment the patient had the cardiac arrest and the crew was already in their vehicle and the crew was able to use the defibrillator by jumping from the vehicle as it arrives and simultaneously placing the pads on the patient's chest and delivering a shock.
Despite, improvements in outcome around the world by getting first responders to focus on these two important measures, in Australia we sit at least 5 years behind in our guidelines on this. In Australia for BLS you would be familiar with the current chart as recommended by the ARC.
What you will notice is that there is a sequencing that places more importance on the management of the patient's airway and ventilations for patients, with the AED at the bottom of the chart. Despite a caveat that the rescuer is "unwilling or unable to performs rescue breaths" they can be omitted; ventilations and airway management are still taught as necessary and are a requirement of CPR certification in Australia, for all types of arrests i.e. CPR certification means you are presumably able (and should) include ventilations in resuscitation attempts.
Whilst ventilations are important in hypoxic arrests (as we discussed in my first post), in the first instance in SCA these make little difference to outcome. A similar problem is also present in the appearance of "Open Airway" as a priority in the guideline. This presumes that all patients are going to receive ventilations (in which case the presence of vomit or solids is usually the only reason to clear an airway) and that a high proportion of patients may have airway obstructions, in which case the application of compressions is the recommended treatment anyway.
In a future post I will look at the lack of evidence around the ARC recommendations on the management of airway obstructions in the conscious patient.
So how should the BLS flowchart look in Australia? Well it should reflect the priorities for the first responder that will make areal difference, good compressions and early defibrillation. As a Paramedic for 15 years the most common complications and delays in the early application of CPR were poor but time consuming airway management and the poor application of ventilation technique leading to vomiting and aspiration (vomit in the lungs). So as a starting point, lets assume we keep the letter acronym DRSABCD, lets rearrange the order of the chart to reflect the priorities for the most common form of arrest that the bystander may face i.e. the SCA.
So here is my first crude attempt at a revised BLS CPR chart. It needs some work, however it does re-order the priorities at least that reflect the evidence. The most important result is that there is a starting point so that training can finally catch up with what we all know, but because of the authority given to the ARC, cannot teach because of a lack of insight by the organisation Australians rely on for recommendations.
Whilst ventilations are important in hypoxic arrests (as we discussed in my first post), in the first instance in SCA these make little difference to outcome. A similar problem is also present in the appearance of "Open Airway" as a priority in the guideline. This presumes that all patients are going to receive ventilations (in which case the presence of vomit or solids is usually the only reason to clear an airway) and that a high proportion of patients may have airway obstructions, in which case the application of compressions is the recommended treatment anyway.
In a future post I will look at the lack of evidence around the ARC recommendations on the management of airway obstructions in the conscious patient.
So how should the BLS flowchart look in Australia? Well it should reflect the priorities for the first responder that will make areal difference, good compressions and early defibrillation. As a Paramedic for 15 years the most common complications and delays in the early application of CPR were poor but time consuming airway management and the poor application of ventilation technique leading to vomiting and aspiration (vomit in the lungs). So as a starting point, lets assume we keep the letter acronym DRSABCD, lets rearrange the order of the chart to reflect the priorities for the most common form of arrest that the bystander may face i.e. the SCA.
So here is my first crude attempt at a revised BLS CPR chart. It needs some work, however it does re-order the priorities at least that reflect the evidence. The most important result is that there is a starting point so that training can finally catch up with what we all know, but because of the authority given to the ARC, cannot teach because of a lack of insight by the organisation Australians rely on for recommendations.
Post 18th August 2015
So considering how important compressions are in resuscitation attempts, what are good compressions and how does the average person achieve these?
In one of my previous posts, we learnt that only 46% of the adult population can achieve adequate depth of compression on an adult patient, that includes health professionals! This figure is at the current recommendations as used in Australia (Depth 50mm and Rate 100/min). This figure is often news to health professionals, who always perceive that prior training or actual clinical experience necessarily means that they are capable of achieving satisfactory compressions. The truth is less than half of us are actually able to achieve and maintain "good compressions".
So what is the "good compression" doing in cardiac arrest, and why is it so important in resuscitation? In my 7th July 2015 post, I set out the findings of ILCOR in regard to the effects of chest compressions however, there is an additional reason why "good compressions" are essential in resuscitation, regardless of the availability of a defibrillator.
Research indicates that another function of chest compressions is to ensure that the heart chambers are relatively empty of old blood, to allow effective pumping of the heart muscle if and when heart function returns. Once the circulation ceases in a patient, there is obviously no blood leaving the heart to perfuse the vital organs and vessels of the body. However, after circulation ceases a more troubling process happens, whereby the vessels of the body as they relax, allow a slow oozing of old venous blood (high in carbon dioxide and low in oxygen) back into the non-functional heart. As a result, the heart rapidly increases in size. This increase in the heart's size can be 60% more than its original size.
So considering how important compressions are in resuscitation attempts, what are good compressions and how does the average person achieve these?
In one of my previous posts, we learnt that only 46% of the adult population can achieve adequate depth of compression on an adult patient, that includes health professionals! This figure is at the current recommendations as used in Australia (Depth 50mm and Rate 100/min). This figure is often news to health professionals, who always perceive that prior training or actual clinical experience necessarily means that they are capable of achieving satisfactory compressions. The truth is less than half of us are actually able to achieve and maintain "good compressions".
So what is the "good compression" doing in cardiac arrest, and why is it so important in resuscitation? In my 7th July 2015 post, I set out the findings of ILCOR in regard to the effects of chest compressions however, there is an additional reason why "good compressions" are essential in resuscitation, regardless of the availability of a defibrillator.
Research indicates that another function of chest compressions is to ensure that the heart chambers are relatively empty of old blood, to allow effective pumping of the heart muscle if and when heart function returns. Once the circulation ceases in a patient, there is obviously no blood leaving the heart to perfuse the vital organs and vessels of the body. However, after circulation ceases a more troubling process happens, whereby the vessels of the body as they relax, allow a slow oozing of old venous blood (high in carbon dioxide and low in oxygen) back into the non-functional heart. As a result, the heart rapidly increases in size. This increase in the heart's size can be 60% more than its original size.
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Click on the heart to the right to download and play a time-lapse video of a heart expanding with blood after cardiac arrest. This video condenses around 5 mins into a 10-second clip.
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As you can see this swelling of the heart is quite dramatic and so emptying of the heart is an important role for compressions during resuscitation as it keeps the heart relatively empty of blood so that if a normal heart rhythm is restored, the heart muscle is once again able to pump blood. Without compressions early (regardless of a defibrillator), the heart would find it very difficult (if not impossible) to pump naturally when it is distended with blood.
So basically compressions to a patient's chest perform four function during resuscitation:
As we said earlier, we need to ask the question what are "good compressions' and how can we achieve them and sustain them in resuscitation. To answer that question, let's have a look at the elements that influence successful compressions:
Strength and Mass - The primary indicator of a rescuer that is best able to achieve and maintain compressions is their strength (particularly of the erector muscles of the back) and their upper body mass. Contrary to the beliefs of many, clinical experience and qualifications mean little when it comes to being able to achieve effective compressions. Research says that effective adult compression require between 50-70kg of force. Remember, anyone can push fast but less than half can get adequate depth. Sadly most resuscitation manikins do not provide an accurate representation of the feel or force required in real resuscitation. There are a few exceptions such as the ALS type AMBU manikins that are calibrated to replicate the force required (but not the feel). Unfortunately being able to achieve a "tick" by a manikin that you have achieved depth, means nothing if the resistant force is not accurate.
Method - The next determinate is the method of compressions the rates, ratios and depths. It is recognised by the international resuscitation community, that rates and depths of compressions are crucial in ensuring that the positive effects are realised. While the rest of the world have increased rates and depths of compressions in response to research, Australia (through the ARC) continues to assert that more conservative rates and depths are somehow better. It is no surprise that survival rates in NSW are falling. The International Liason Committee on Resuscitation (ILCOR) draft guidelines for 2015 reflect the European standards e.g. for Adults a depth of 60mm and every patient compressed at a rate of 120/min (two a second). While this will create additional challenges trying to achieve this new standard, the evidence is that it better for the patient.
Before we continue let's clear up one of the common myths people rely on for estimating the depth of compressions. The mantra often spouted is that to estimate the depth of compression on any patient a rescuer need only to push down a 1/3 of the depth of the patient's chest. There are a few problems with this theory:
Technique - The technique of compressions does make a difference as to how effective, sustainable and difficult it becomes. The first element to tackle is hand grip (or digit position in babies). Most trainers and web, describe the "interlocking fingers" technique.
So basically compressions to a patient's chest perform four function during resuscitation:
- Compressions empty the heart of old venous blood that pools there after the heart has stopped.
- Compressions of the chest decrease the size of the chest and increase the internal pressure, this acts to pressurise blood in large vessels in the chest, like the aorta (the large vessel that comes from the top of the heart) and this blood is forced away from the chest and returns when the compression is released. Blood is not circulated by compressing the heart and squeezing blood from the squashed heart through the circulatory system.
- Compressions force some blood in the aorta into the carotid and coronary arteries (which supply the brain and heart muscle with blood) and so a small amount of perfusion takes place, of these important organs.
- Compressions create passive ventilation (in the order of 300-400ml of TV). In the case of a Sudden Cardiac Arrest (SCA) this passive ventilation is adequate for resuscitation attempts by lay rescuers.
As we said earlier, we need to ask the question what are "good compressions' and how can we achieve them and sustain them in resuscitation. To answer that question, let's have a look at the elements that influence successful compressions:
- The strength and mass of the rescuer.
- The method used i.e what rates, ratios and depths are best.
- The technique used i.e. how compressions can be most effectively done on patients of different size and within the limitations of the rescuer.
Strength and Mass - The primary indicator of a rescuer that is best able to achieve and maintain compressions is their strength (particularly of the erector muscles of the back) and their upper body mass. Contrary to the beliefs of many, clinical experience and qualifications mean little when it comes to being able to achieve effective compressions. Research says that effective adult compression require between 50-70kg of force. Remember, anyone can push fast but less than half can get adequate depth. Sadly most resuscitation manikins do not provide an accurate representation of the feel or force required in real resuscitation. There are a few exceptions such as the ALS type AMBU manikins that are calibrated to replicate the force required (but not the feel). Unfortunately being able to achieve a "tick" by a manikin that you have achieved depth, means nothing if the resistant force is not accurate.
Method - The next determinate is the method of compressions the rates, ratios and depths. It is recognised by the international resuscitation community, that rates and depths of compressions are crucial in ensuring that the positive effects are realised. While the rest of the world have increased rates and depths of compressions in response to research, Australia (through the ARC) continues to assert that more conservative rates and depths are somehow better. It is no surprise that survival rates in NSW are falling. The International Liason Committee on Resuscitation (ILCOR) draft guidelines for 2015 reflect the European standards e.g. for Adults a depth of 60mm and every patient compressed at a rate of 120/min (two a second). While this will create additional challenges trying to achieve this new standard, the evidence is that it better for the patient.
Before we continue let's clear up one of the common myths people rely on for estimating the depth of compressions. The mantra often spouted is that to estimate the depth of compression on any patient a rescuer need only to push down a 1/3 of the depth of the patient's chest. There are a few problems with this theory:
- On an Adult 1/3 of the chest depth is not achievable. In fact, the ARC admits this in the fine print of their guidelines. The most depth achievable on an adult is approximately 15-20% of the chest depth.
- The second issue is how does a rescuer measure 1/3 of the chest depth when they are viewing it from the top as they do compressions. Either someone else has to evaluate the chest depth or the sole rescuer has to have an out-of-body experience and watch themselves doing their own compressions from the side to calculate 1/3.
Technique - The technique of compressions does make a difference as to how effective, sustainable and difficult it becomes. The first element to tackle is hand grip (or digit position in babies). Most trainers and web, describe the "interlocking fingers" technique.
This technique was introduced many years ago in an attempt to reduce rib fractures by holding the fingers off the chest. The truth is, the force of compressions is exerted through the ball of the lower hand and regardless of how many fingers are in contact with the chest it will not change the occurrence of rib fractures; they are just part of pushing a patient's chest down 60 mm and generally don't cause any additional problems. The real problem with this technique is that what the rescuer is doing in using this technique is hyperextending the wrist of the lower hand and this leads to not just wrist pain but in some instances wrist damage. A better technique is the "locked wrist" technique. In this technique, the thumb and index finger of the upper hand grip around the wrist of the lower hand (at the level of that little bump on the little finger side on the back of your wrist). In this position, the wrist of the lower hand is supported, braced and protected during compressions. In fact the only time I would use the interlocking fingers technique is if I every came across a plastic manikin arrested in the street- unlikely!
The other important element in good compressions is making the best use of your body mass. The way to do this with the traditional kneeling technique for an adult is to move your knees back till your thighs are vertical, with your elbows locked and pivoting from the hips rather than knees. If your knees are too close the patient then the stress will be on your erector muscles and they will fatigue quickly. If your knees are too far away you will tend to pivot at the knees rather than the hips and most of your force will be directed sideways rather than straight down. On an adult, the traditional kneeling technique is not the only way to do good compressions and for some people who a weak, light or have injuries or disabilities it is impossible/ineffective. There are of course several devices that can assist with compression however, they are not usually carried by the average people who are faced with a cardiac arrest. An alternative technique for these situations is "foot compressions". If you click on the link you will find a paper I wrote about this technique that I forwarded to the ARC some months ago for inclusion in the new guidelines <click here>. The other benefit of this technique (apart from 20% more force), is that it is the only technique that can maintain depth of compressions, over time.
With children and babies (paediatrics), there are also a few tips to make this more effective. With young children (what looks like it is between 1 and 8 years), one hand should be sufficient but just remember that there are no rules here, so if the patient is stiff or you are getting tired, then use two hands (like an adult). For babies (look like they are under 12 months), the traditional 2 finger technique as recommended by the ARC is very poor at providing sufficient pressure change in the chest (essential for effectiveness). The best method, supported by clinical evidence and used by every neonatal ward in Australia is the 2 thumb technique. A few years ago a couple of doctors developed a third technique using two fingers but proved to be clinically superior to the traditional two finger technique and showed no increase in complications caused by compressions.
The other important element in good compressions is making the best use of your body mass. The way to do this with the traditional kneeling technique for an adult is to move your knees back till your thighs are vertical, with your elbows locked and pivoting from the hips rather than knees. If your knees are too close the patient then the stress will be on your erector muscles and they will fatigue quickly. If your knees are too far away you will tend to pivot at the knees rather than the hips and most of your force will be directed sideways rather than straight down. On an adult, the traditional kneeling technique is not the only way to do good compressions and for some people who a weak, light or have injuries or disabilities it is impossible/ineffective. There are of course several devices that can assist with compression however, they are not usually carried by the average people who are faced with a cardiac arrest. An alternative technique for these situations is "foot compressions". If you click on the link you will find a paper I wrote about this technique that I forwarded to the ARC some months ago for inclusion in the new guidelines <click here>. The other benefit of this technique (apart from 20% more force), is that it is the only technique that can maintain depth of compressions, over time.
With children and babies (paediatrics), there are also a few tips to make this more effective. With young children (what looks like it is between 1 and 8 years), one hand should be sufficient but just remember that there are no rules here, so if the patient is stiff or you are getting tired, then use two hands (like an adult). For babies (look like they are under 12 months), the traditional 2 finger technique as recommended by the ARC is very poor at providing sufficient pressure change in the chest (essential for effectiveness). The best method, supported by clinical evidence and used by every neonatal ward in Australia is the 2 thumb technique. A few years ago a couple of doctors developed a third technique using two fingers but proved to be clinically superior to the traditional two finger technique and showed no increase in complications caused by compressions.
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The traditional "two-finger" technique of compressions on an infant offers little. |
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. If t
The two thumb technique is a superior method used by all hospitals over the traditional two-finger technique. If the hand are not large enough to reach around the infant, the other fingers can be made into fists and thumbs only used to compress the chest. |
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The new two-finger technique has proven in clinical trials to be superior in every way to the old two-finger method. |
The final technique for babies is to do CPR with the child on your arm. In this method, the infant is laid on your forearm face-up with the head cradle in your hand to maintain the neutral head position. The baby's legs should fall each side of your arm i.e. the baby's crutch is up against the inside of your elbow. If your arm isn't long enough then just tuck both legs underneath your armpit and squeeze the legs to hold securely. In this position, the baby can be rolled to clear vomit, compressions using the new two-finger technique and ventilations can be performed. The benefit of this technique is that you are now fully mobile to go to help while continuing resuscitation. In remote areas, you could even continue CPR while someone else drives to meet the Ambulance en-route.
Post 10th February 2016
The ARC has recently released its December 2015 changes post the ILCOR meeting in October 2015. Essentially, the only changes to BLS, sort of bring the ARC guidelines in line with the ERC guidelines that have been in place for many years. The two elements of CPR which are clear in the rest of the world are the increase of compression rate to 120/min (for all patients) and the increase in compression depth to an upper limit of 60mm (in adults). Despite this change across the world the ARC has decided not to change its fundamental advice
"The recommendations regarding depth of compression are unchanged however ANZCOR does acknowledge evidence suggesting detriment with compression depths greater than 6cm. In making the decision not to change our current recommendations (sternum should be depressed approximately one third of the depth of the chest with each compression. This equates to more than 5cm in adults, approximately 5cm in children and 4 cm in infants)"
Interestingly, the ARC assessment of 1/3 of the depth of the chest in children and infants has been corrected in this statement, as their previous advice was not anatomically correct. However, the advice still contains the erroneous advice that 50-60mm on an Adult is equivalent to 1/3 of the depth of the chest. As I have explained in previous posts, the notion of 1/3 in Adults, despite being impossible to assess from above for the single rescuer, is also anatomically incorrect as 50-60mm represents 15-20% of the chest depth (a fact recognised in the previous ARC guidelines but disregarded).
BLS - Summary of Changes December 2015
BASIC LIFE SUPPORT GUIDELINES
SUMMARY OF CHANGES
"The only change to the ANZCOR BLS guidelines in light of the release of the ILCOR Consensus on Science and Treatment Recommendations is related to rate of chest compressions and this has changed from “approximately 100” to “100 to 120 compressions per minute”. ANZCOR acknowledges that compression rates will vary between and within providers and there is evidence that survival rates are optimised at compressions rates of 100-120 compressions per minute. There is some evidence that compressions rates less than 100 or greater than 140 compressions per minute are associated with lower rates of survival.
The recommendations regarding depth of compression are unchanged however ANZCOR does acknowledge evidence suggesting detriment with compression depths greater than 6cm. In making the decision not to change our current recommendations (sternum should be depressed approximately one third of the depth of the chest with each compression. This equates to more than 5cm in adults, approximately 5cm in children and 4 cm in infants), ANZCOR has taken the view that the clinical reality of being able to tell the difference between 5 or 6 cm and adjust compressions accordingly is questionable. Inadequate compression depth is definitely associated with poor outcomes. ANZCOR has elected not to put an upper limit on compression depth as the risk of too shallow compressions outweighs the risk of compressions that are too deep."
The rest of the BLS guidelines are essentially the same. The ARC has tried to move a little toward an emphasis on compressions first of "rescue breaths" (this assumes all BLS is via expired air resuscitation) in the DRSABCD flowchart, however this in practice is not clear and really does not differentiate themselves from the old guidelines.
The ARC has recently released its December 2015 changes post the ILCOR meeting in October 2015. Essentially, the only changes to BLS, sort of bring the ARC guidelines in line with the ERC guidelines that have been in place for many years. The two elements of CPR which are clear in the rest of the world are the increase of compression rate to 120/min (for all patients) and the increase in compression depth to an upper limit of 60mm (in adults). Despite this change across the world the ARC has decided not to change its fundamental advice
"The recommendations regarding depth of compression are unchanged however ANZCOR does acknowledge evidence suggesting detriment with compression depths greater than 6cm. In making the decision not to change our current recommendations (sternum should be depressed approximately one third of the depth of the chest with each compression. This equates to more than 5cm in adults, approximately 5cm in children and 4 cm in infants)"
Interestingly, the ARC assessment of 1/3 of the depth of the chest in children and infants has been corrected in this statement, as their previous advice was not anatomically correct. However, the advice still contains the erroneous advice that 50-60mm on an Adult is equivalent to 1/3 of the depth of the chest. As I have explained in previous posts, the notion of 1/3 in Adults, despite being impossible to assess from above for the single rescuer, is also anatomically incorrect as 50-60mm represents 15-20% of the chest depth (a fact recognised in the previous ARC guidelines but disregarded).
BLS - Summary of Changes December 2015
BASIC LIFE SUPPORT GUIDELINES
SUMMARY OF CHANGES
"The only change to the ANZCOR BLS guidelines in light of the release of the ILCOR Consensus on Science and Treatment Recommendations is related to rate of chest compressions and this has changed from “approximately 100” to “100 to 120 compressions per minute”. ANZCOR acknowledges that compression rates will vary between and within providers and there is evidence that survival rates are optimised at compressions rates of 100-120 compressions per minute. There is some evidence that compressions rates less than 100 or greater than 140 compressions per minute are associated with lower rates of survival.
The recommendations regarding depth of compression are unchanged however ANZCOR does acknowledge evidence suggesting detriment with compression depths greater than 6cm. In making the decision not to change our current recommendations (sternum should be depressed approximately one third of the depth of the chest with each compression. This equates to more than 5cm in adults, approximately 5cm in children and 4 cm in infants), ANZCOR has taken the view that the clinical reality of being able to tell the difference between 5 or 6 cm and adjust compressions accordingly is questionable. Inadequate compression depth is definitely associated with poor outcomes. ANZCOR has elected not to put an upper limit on compression depth as the risk of too shallow compressions outweighs the risk of compressions that are too deep."
The rest of the BLS guidelines are essentially the same. The ARC has tried to move a little toward an emphasis on compressions first of "rescue breaths" (this assumes all BLS is via expired air resuscitation) in the DRSABCD flowchart, however this in practice is not clear and really does not differentiate themselves from the old guidelines.
Post 17th February 2016
I decided after reading the disappointing lack of positive change in the 2016 ARC Guidelines that it was time to open a discussion in Australia as to if we need to have an alternative guideline source for BLS. After a lot of work I have now launched a new non-profit association for BLS guidance. This entity is called the Australian Resuscitation Advisory Network (ARAN) and is a registered entity with its own website www.aran.org.au where you can find my first revised BLS guidelines and flowcharts. I will be regularly posting new guidelines and welcome feedback and suggestions from anyone involved in CPR delivery and/or training.
I am convinced that the current BLS guidelines are not best practice and do not focus on the elements of BLS that save lives prior to Ambulance assistance. The current position of the ARC is not to advocate for WHS changes and Government policy improvements (such as allowing AED's in schools and insisting these are not only mandatory in public areas and businesses, but pressuring Government to engage in a widespread Public Access Defibrillation Programs to inform the public that they are allowed to use these and what they are for).
I decided after reading the disappointing lack of positive change in the 2016 ARC Guidelines that it was time to open a discussion in Australia as to if we need to have an alternative guideline source for BLS. After a lot of work I have now launched a new non-profit association for BLS guidance. This entity is called the Australian Resuscitation Advisory Network (ARAN) and is a registered entity with its own website www.aran.org.au where you can find my first revised BLS guidelines and flowcharts. I will be regularly posting new guidelines and welcome feedback and suggestions from anyone involved in CPR delivery and/or training.
I am convinced that the current BLS guidelines are not best practice and do not focus on the elements of BLS that save lives prior to Ambulance assistance. The current position of the ARC is not to advocate for WHS changes and Government policy improvements (such as allowing AED's in schools and insisting these are not only mandatory in public areas and businesses, but pressuring Government to engage in a widespread Public Access Defibrillation Programs to inform the public that they are allowed to use these and what they are for).
Post 28th May 2016
Today the BBC reported that the 96-year-old American inventor of the Heimlich Manoeuvre has used the technique himself to save a choking woman at his retirement home. Dr Henry Heimlich said he had demonstrated the technique many times but never used it in an emergency. His action dislodged a piece of meat with a bone in it from the 87-year-old woman's airway.
Since the technique was introduced in 1974 it is believed to have saved the lives of more than 100,000 people in the US alone.
They include former President Ronald Reagan, pop star Cher, former New York mayor Edward Koch and Hollywood actors Elizabeth Taylor, Goldie Hawn, Walter Matthau, Carrie Fisher, Jack Lemmon and Marlene Dietrich. In 2014 actor Clint Eastwood was credited with saving the life of a golf tournament director in California who was choking on a piece of cheese. In the UK, celebrity promoter Simon Cowell was reportedly saved by comedian David Walliams, who carried out the Heimlich Manoeuvre on him after a mint became stuck in his throat.
Despite a well documented history of successful saves using this technique, Australia continues to be the only place in the world where the Heimlich Manoeuvre is not recommended by its national resuscitation authority (ARC). With no clinical or scientific evidence, Australians are told to use a uniquely Australian variant of the "chest thrust" technique. In support of this Australian technique we should have many documented cases of people being saved, without the Heimlich Manoeuvre; unfortunately we don't.
Today the BBC reported that the 96-year-old American inventor of the Heimlich Manoeuvre has used the technique himself to save a choking woman at his retirement home. Dr Henry Heimlich said he had demonstrated the technique many times but never used it in an emergency. His action dislodged a piece of meat with a bone in it from the 87-year-old woman's airway.
Since the technique was introduced in 1974 it is believed to have saved the lives of more than 100,000 people in the US alone.
They include former President Ronald Reagan, pop star Cher, former New York mayor Edward Koch and Hollywood actors Elizabeth Taylor, Goldie Hawn, Walter Matthau, Carrie Fisher, Jack Lemmon and Marlene Dietrich. In 2014 actor Clint Eastwood was credited with saving the life of a golf tournament director in California who was choking on a piece of cheese. In the UK, celebrity promoter Simon Cowell was reportedly saved by comedian David Walliams, who carried out the Heimlich Manoeuvre on him after a mint became stuck in his throat.
Despite a well documented history of successful saves using this technique, Australia continues to be the only place in the world where the Heimlich Manoeuvre is not recommended by its national resuscitation authority (ARC). With no clinical or scientific evidence, Australians are told to use a uniquely Australian variant of the "chest thrust" technique. In support of this Australian technique we should have many documented cases of people being saved, without the Heimlich Manoeuvre; unfortunately we don't.
Post 28th May 2016
The European Resuscitation Council (ERC) has released their new guidelines, including now recommending that the BLS Guidelines for Children be the same as the ALS Guidelines (see below). This includes using the ratio of 15:2 for CPR due to the high likelihood that a paediatric arrest will by caused by a hypoxic episode.
The European Resuscitation Council (ERC) has released their new guidelines, including now recommending that the BLS Guidelines for Children be the same as the ALS Guidelines (see below). This includes using the ratio of 15:2 for CPR due to the high likelihood that a paediatric arrest will by caused by a hypoxic episode.
