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Basic Life Support (BLS) & Cardiopulmonary Resuscitation(CPR) Clinical Guideline for General Practice

Clinical Guideline CL069

Version Number: Version 2; April 2011

Issued Date: 18 April 2011

Review Date: 31 March 2013

Sponsoring Director: Medical Director

Prepared By: General Practice CPR Guideline Development Group

ConsultationProcess:

Medical Director, Dr Kat Noble, Dr Ahmet Fuat, Dr IanDavidson, Nursing and Clinical Quality Advisor

Formally Approved: 9 March 2011

Policy Adopted From: N/A

Approval Given By: Senior Management Team, Medical Directorate

Document History

Version Date Signif icant Changes

2 April 2011 Amended section 4 to reflect the new Boardarrangements

Equality Impact Assessment

Date Issues

N/A

POLICY VALIDITY STATEMENTThis policy is due for review on the latest date shown above. After this date, policy andprocess documents may become invalid.Policy users should ensure that they are consulting the currently valid version of the

documentation.

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ContentsSection Title Page

1 Introduction 3

2 Definitions 4

3 Guideline detail 5

4 Duties And Responsibilities 6

5 Implementation 6

6 Training Implications 7

7 Documentation 7

8 Monitoring, Review And Archiving 8

9 Equality Impact Assessment Statement 9

Appendices

1 Chain of Survival 10

2 BLS Guideline11

3 Defibrillator Guideline 17

4 BLS Required Equipment List 22

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Basic Life Support (BLS) & Cardiopulmonary Resuscitation

(CPR) Clinical Guideline for General Practice

1. Introduction

NHS County Durham and Darlington aspires to the highest standards ofcorporate behaviour and clinical competence, to ensure that safe, fair andequitable procedures are applied to all organisational transactions, includingrelationships with patients their carers, public, staff, stakeholders and the useof public resources. In order to provide clear and consistent guidance, NHSCounty Durham and Darlington will develop documents to fulfil all statutory,organisational and best practice requirements and support the principles ofequal opportunity for all.

Sudden cardiac arrest, particularly from coronary heart disease remains oneof the commonest causes of death in the United Kingdom. The ResuscitationCouncil (UK) advocates that the correct treatment must be given immediatelyif the patient is to have any chance of surviving. The interventions thatcontribute to a successful outcome after a cardiac arrest can beconceptualised as a chain the Chain of Survival. This is shown in appendix1.

The National Service Framework for Coronary Heart Disease recognises the

importance of early defibrillation, it specifies that patients with symptoms of aheart attack should be attended to by someone trained and equipped todefibrillate within 8 minutes of calling for help to maximise the chance ofsuccessful defibrillation, should it be necessary. However, more recentResuscitation Guidelines (Resuscitation Council (UK), 2010), states that anAutomated External Defibrillator (AED) can be used safely and effectivelywithout previous training; its use should not be restricted to trained rescuers.

Al l employees of a GP pract ice may be required to resuscitate a v ic timof cardiopulmonary arrest. It is unacceptable for anyone who sustains acardiopulmonary arrest to await the arrival of the ambulance service

before basic resuscitation is performed and a defibril lator is available.

1.1 Status

This document is aclinical guideline developed for use by GP practicepersonnel and is based upon the latest national and international clinicalevidence

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1.2 Purpose and scope

This guideline aims to provide best practice relating to current resuscitationstandards and training for those working in GP practices in NHS CountyDurham and Darlington. Although the persons most likely to attemptcardiopulmonary resuscitation (CPR) are general practitioners and nursingstaff, all members of staff, including administrative staff may contribute directlyor indirectly. Reception and administrative staff may make a very importantcontribution, as they often receive urgent calls and summon the emergencyservices.

It is important to note that training and practice are necessary to acquire andmaintain skills in CPR techniques. A consensus view, based on studies ofcomparable providers suggest that doctors and nurses should have refresher

training in basic life support (BLS) and use of AED every twelve months.This guideline provides a framework which supports professional practice andadvocates that all members of the practice are trained and equipped toresuscitate patients who suffer cardiopulmonary arrest.

This guideline also aims to;

reduce mortality and morbidity of those who have suffered a respiratoryor cardiac arrest

advocate that all employees of the GP practice are trained in BLS

This guideline does not cover techniques which constitute Advanced Life

Support (ALS) and does not cover anaphylaxis.

2. Definitions

The following terms are used in this document:

AED Automated External DefibrillatorALS Advanced Life SupportBLS Basic Life Support

CAS Central Alert System the system by which the Department ofHealth and PCT disseminate alerts relating to patient safetyissues

CPR Cardiopulmonary resuscitationDNAR Do Not Attempt Attempt Resuscitation the term given to the

notice relating to the circumstances when resuscitation of anindividual should not be attempted

ILS Intermediate Life SupportPBLS Paediatric Basic Life SupportPCT Primary Care Trust

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3. Guideline detail

3.1 All staff members of the GP practice should be trained on an annual

basis to resuscitate those who have a cardiopulmonary arrest usingBLS/PBLS skills. Current guidelines from Resuscitation Council (UK) for themanagement of cardiopulmonary arrest must be followed.

This clinical guideline also advocates that all staff members should be trainedto use an AED. Rescuers begin CPR if the victim is unconscious orunresponsive and not breathing normally (ignoring occasional gasps). Asingle compression-ventilation (CV) ratio of 30:2 is used by the single rescuerof an adult or child (excluding newborn) out of hospital, and for all adult CPR.Specific guidelines relating to BLS (and PBLS) and the use of an AED areshown in appendices 2 and 3.

3.2 In the interests of patient safety, any GP or registered nurse whowishes to use ALS skills (including the administration of drugs) must bespecifically trained to do so on an annual basis by an accredited provider.

3.3 Cardiopulmonary arrest occurring in general practice is recognised asa significant event/serious untoward incident and should be investigated assuch any lessons learnt from the event should be implemented to preventrecurrence where possible. All staff must contribute to any cardiopulmonaryarrest investigation and subsequent audit.

3.4 Resuscitation equipment is used relatively infrequently and therefore allstaff must know where resuscitation equipment is kept and be trained on itsuse. Equipment should be checked on a weekly basis to ensure it is allpresent and in-date and a written/electronic copy of the check should be keptfor validation purposes. All electronic equipment must be annually tested forsafety reasons and replaced immediately if deemed to be not fit for use. Astandard defibrillator sign should be placed at the location of the AED so thatit is visible for all to see (the defibrillator sign is available from theResuscitation Council (UK) website to download athttp://www.resus.org.uk/pages/AEDsignP.htm). Please refer to appendix 4 fora list of recommended equipment for BLS and AED use.

3.5 Resuscitation equipment may, from time-to-time, be the subject ofpatient safety alerts. All GP practices must have electronic systems in placeto be able to receive and implement patient safety alerts issued by the CentralAlert Systems (CAS), via the PCT, within the timescales stipulated by thealert.

3.6 A DNAR decision applies specifically to CPR and to no other treatment.Patients for whom CPR will not prolong life, but may merely prolong the dyingprocess, should be identified early and CPR should not be attempted on thosewhere a DNAR decision has been made and where knowledge of the DNAR

notice has been communicated and is apparent. However, CPR should notbe withheld in cases where DNAR status is not known at the time of the

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emergency. A standardised form should be used to record and communicateall DNAR decisions and DNAR decisions should be reviewed wheneverclinically appropriate, but particularly when there is a significant change in thepatients clinical condition or when the patient is transferred from onehealthcare setting to another. Further guidance on DNAR and Advanced

Decisions to Refuse Treatment (ADRT) are available via professional bodies.

4. Duties and Responsibilit ies

4.1 The Board:The Statutory Board has delegated responsibility to the J oint Board (JB) forsetting the strategic context in which organisational process documents aredeveloped, and for establishing a scheme of governance for the formal reviewand approval of such documents

4.2 Joint Chief ExecutiveThe J oint Chief Executive has overall responsibility for the strategic directionand operational management, including ensuring that Trust processdocuments comply with all legal, statutory and good practice guidancerequirements.

4.3 Medical DirectorThe Medical Director is the sponsoring director for this document and isresponsible for ensuring that:

This guideline reflects current national and international resuscitationevidence-based guidelines

This guideline is updated when changes to the evidence-base occurs

This guideline is disseminated to all GP practices

4.4 General Practice CPR Guideline Development Group The General Practice CPR Guideline Development Group will:

Amend this guideline to reflect the latest clinical evidence

5. Implementation

This guideline will be available to all GP practices within the geographicalboundary of County Durham and Darlington for usein the circumstancesdescribed on the title page.

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6. Training Implications

It is recommended that all GP practice staff receive annual training on BLS

and the use of AEDs. BLS training should be delivered by a training providerwho is an accredited instructor with the Resuscitation Council (UK) andtraining must reflect current Resuscitation Council (UK) Guidance andEuropean Resuscitation Council Guidelines and include both adult andpaediatric BLS skills including;

the recognition of cardiopulmonary arrest the requirement to summon help instruction to start CPR using airway adjuncts and attempt defibrillation

within 3 minutes of collapse.

AED training should include the following principles;

importance of an definition of defibrillation Resuscitation Council (UK) Guidance/protocols rhythm recognition recognition of cardiac arrest safety of the recipient of BLS, the operator and other personnel placement of electrodes demonstration of correct defibrillation technique practice allowing each student the time to run through at least one total

procedure from start to finish

cardiac arrest management scenarios to include BLS, airwaymanagement, cardiac arrest rhythm recognition and defibrillation pass Resuscitation Council (UK) competencies for automated external

defibrillation

The GP practice will be responsible for co-ordinating CPR training provision.All new members of staff should have CPR training as part of their inductionprogramme.

Following training, all personnel must be able to demonstrate competence inall principles of training. Where competence is achieved, the trainer must

provide evidence of completion of training for governance purposes. A recordof staff who have completed training must be kept within the practice thisshould include the date on which staff receive training and the date on whichthey are due to receive re-training.

Any GP or nurse who wishes to pract ice ALS/ILS techniques mustreceive annual t raining on ALS/ILS skills f rom a Resuscitation Council(UK) accredited provider.

7. Documentation

7.1 Other related policy documents.

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NHS County Durham and Darlington, (2010) Policy for the Management andReporting of Untoward Incidents and Near Misses (CO 009)

NHS County Durham and Darlington, (2010) Policy and Procedure Guidance

for the reporting of Serious Untoward Incidents (SUIs) (CG 001)

7.2 Legislation and statutory requirements

Cabinet Office, (1974) Health & Safety at Work etc Act, 1974, LondonCabinet Office, (1999), Management of Health & Safety at Work Regulations,1999, LondonCabinet Office, (1995), The Reporting of Injuries, Diseases and DangerousOccurrences Regulations, 1995 (RIDDOR), LondonCabinet Office, (1998), Human Rights Act, 1998, London

Cabinet Office, (2001), Freedom of Information Act, 2001, LondonCabinet Office, (2005), Mental Capacity Act, 2005, LondonCabinet Office, (2007), MCA Code of Practice, 2007, LondonCabinet Office, (2006), Equality Act, 2006, London

7.3 Best practice recommendations

European Resuscitation Council (2010), Resuscitation Guidelines, 2010.Resuscitation Council (UK), (2010), Resuscitation Guidelines. London: RC(UK)

Department of Health. (2008) Records Management: NHS Code ofPractice. London: DH.Department of Health (2000) National Service Framework Coronary HeartDisease. London: DH.

7.4 References

The major references consulted in preparing this document are describedabove.

8. Monitor ing, Review and Archiving

8.1 MonitoringThe Medical Director, as sponsor director will agree with the General PracticeCPR Guideline Development Group, a method for monitoring thedissemination and implementation of this guideline.

8.2 Review

8.2.1 The Medical Director will ensure that this document is reviewed in accordancewith the timescale specified at the time of approval. No policy, procedure or

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guideline will remain operational for a period exceeding three yearswithout a review taking place.

8.2.2 Staff who become aware of changes in practice, changes to statutoryrequirements, revised professional or clinical standards and local/national

directives that affect, or could potentially affect documents, should advise thesponsoring director as soon as possible, via line management arrangements.

The sponsoring director will then consider the need to review the policy,procedure or guideline outside of the agreed timescale for revision.

8.2.3 If the review results in changes to the document, then the initiator shouldinform the policy manager who will renew the approval and re-issue under thenext version number. If, however, the review confirms that no changes arerequired, the title page should be renewed indicating the date of the reviewand date for the next review and the title page only should be re-issued.

8.2.4 For ease of reference for reviewers or approval bodies, changes should benoted in the document history table on the front page of this document.

NB: If the review consists of a change to an appendix or procedure document,approval may be given by the sponsor director and a revised document maybe issued. Review to the main body of the guideline must always follow theoriginal approval process.

8.3 ArchivingThe Policy Manager will ensure that archived copies of supersededdocuments are retained in accordance with Records Management: NHS Codeof Practice 2008.

9 Equality Impact Assessment Statement

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Appendix 1

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Appendix 2

Basic Life Support (BLS) Guideline

Introduction

Adul t basic l ife support sequence

Basic life support consists of the following sequence of actions:

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

2. Check the victim for a response.

Gently shake the victims shoulders and ask loudly, Are you all right?

3A. If the victim responds:

Leave the victim in the position in which you find him/her provided there is nofurther danger.

Try to find out what is wrong with the victim and get help if needed.

Reassess the victim regularly.

3B. If the victim does not respond:

Shout for help.

Turn the victim onto his/her back and then open the airway using head tilt and chin

lift: Place your hand on the victims forehead and gently tilt his/her head back. 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, ortaking infrequent, noisy, gasps. This is often termed agonal breathing and must notbe confused with normal breathing.

Look, listen, and feel for no more than 10 s to determine if the victim is breathingnormally. If you have any doubt whether breathing is normal, act as if it is notnormal.

5A. If the victim is breathing normally:

Turn the victim into the recovery position

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.

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Continue to assess that breathing remains normal. If there is any doubt about thepresence of normal breathing, start CPR (5B).

5B. If the victim 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 onlywhen no other option exists for getting help.

Start chest compression as follows: Kneel by the side of the victim. Place the heel of one hand in the centre of the victims chest (which is the

lower half of the victims sternum (breastbone)). Place the heel of your other hand on top of the first hand. 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 abdomenor the bottom end of the sternum.

Position yourself vertically above the victim's chest and, with your armsstraight, press down on the sternum 5 - 6 cm.

After each compression, release all the pressure on the chest withoutlosing contact between your hands and the sternum.

Repeat at a rate of 100 - 120 min-1. 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 victims nose closed, using the index finger and thumb ofyour hand on his/her forehead.

Allow the victims mouth to open, but maintain chin lift.Take a normal breath and place your lips around the victims mouth, making surethat you have a good seal.

Blow steadily into the victims mouth whilst watching for his/her chest to rise; takeabout one second to make his/her chest rise as in normal breathing; this is aneffective rescue breath.

Maintaining head tilt and chin lift, take your mouth away from the victim and watchfor his/her chest to fall as air comes out.

Take another normal breath and blow into the victims mouth once more to give atotal 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/she starts to show signs of regainingconsciousness, such as coughing, opening his/her eyes, speaking, or movingpurposefully AND starts to breathe normally; otherwise do not interruptresuscitation.

If the initial rescue breath of each sequence does not make the chest rise as innormal 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.

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Do not attempt more than two breaths each time before returning to chestcompressions.If there is more than one rescuer present, another should take over CPR about every1-2 min to prevent fatigue. Ensure the minimum of delay during the changeover ofrescuers, and do not interrupt chest compressions.

6B. Compression-only CPR

If you are not trained to, or are unwilling to give rescue breaths, give chestcompressions 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/she starts to show signs of regainingconsciousness, such as coughing, opening his eyes, speaking, or movingpurposefully AND starts to breathe normally; otherwise do not interruptresuscitation.

7. Continue resuscitation unti l:

qualified help arrives and takes over,

the victim starts to show signs of regaining consciousness, such as coughing,opening his/her eyes, speaking, or moving purposefully AND starts to breathenormally, OR

you become exhausted.

Further points related to basic life support

Risks to the rescuer and vict im

The safety of both the rescuer and victim are paramount during a resuscitationattempt. There have been few incidents of rescuers suffering adverse effects fromundertaking CPR, with only isolated reports of infections such as tuberculosis (TB)and severe acute respiratory distress syndrome (SARS). Transmission of HIV duringCPR has never been reported.

There have been no human studies to address the effectiveness of barrier devicesduring CPR; however, laboratory studies have shown that certain filters, or barrierdevices with one-way valves, prevent transmission of oral bacteria from the victim tothe rescuer during mouth-to-mouth ventilation. Rescuers should take appropriate

safety precautions where feasible, especially if the victim is known to have a seriousinfection such as TB or SARS. During an outbreak of a highly infectious condition(such as SARS), full protective precautions for the rescuer are essential.

Initial rescue breaths

During the first few minutes after non-asphyxial cardiac arrest the blood oxygencontent remains high. Therefore, ventilation is less important than chest compressionat this time. It is well recognised that skill acquisition and retention are aided bysimplification of the BLS sequence of actions. It is also recognised that rescuers arefrequently unwilling to carry out mouth-to-mouth ventilation for a variety of reasons,including fear of infection and distaste for the procedure. For these reasons, and to

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emphasise the priority of chest compressions, it is recommended that, in adults,CPR should start with chest compressions rather than initial ventilations.

Jaw thrust

The jaw thrust technique is not recommended for lay rescuers because it is difficultto learn and perform. Therefore, the lay rescuer should open the airway using ahead-tilt chin- lift manoeuvre for both injured and non-injured victims.

Agonal gasps

Agonal gasps are present in up to 40% of cardiac arrest victims. Therefore laypeopleshould be taught to begin CPR if the victim is unconscious (unresponsive) and notbreathing normally. It should be emphasised during training that agonal gasps occur

commonly in the first few minutes after sudden cardiac arrest; they are an indicationfor starting CPR immediately and should not be confused with normal breathing.

Use of oxygen during basic life support

There is no evidence that oxygen administration is of benefit during basic life supportin the majority of cases of cardiac arrest before healthcare professionals areavailable with equipment to secure the airway. Its use may lead to interruption inchest compressions, and is not recommended, except in cases of drowning.

Mouth-to-nose ventilation

Mouth-to-nose ventilation is an effective alternative to mouth-to-mouth ventilation. Itmay be considered if the victims mouth is seriously injured or cannot be opened, ifthe rescuer is assisting a victim in the water, or if a mouth-to-mouth seal is difficult toachieve.

Chest compression

In most circumstances it will be possible to identify the correct hand position forchest compression without removing the victims clothes. If in any doubt, removeouter clothing.Each time compressions are resumed on an adult, the rescuer should place his/herhands on the lower half of the sternum. It is recommended that this location betaught in a simple way, such as place the heel of your hand in the centre of thechest with the other hand on top. This teaching should be accompanied by ademonstration of placing the hands on the lower half of the sternum. Use of theinternipple line as a landmark for hand placement is not reliable.

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Performing chest compression:a. Compress the chest at a rate of 100-120 min-1.b. Each time compressions are resumed, place your hands without delay in thecentre of the chest (see above).c. Pay attention to achieving the full compression depth of 5-6 cm (for an adult).

d. Allow the chest to recoil completely after each compression.e. Take approximately the same amount of time for compression and relaxation.f. Minimise interruptions in chest compression.g. Do not rely on a palpable carotid or femoral pulse as a gauge of effective arterialflow.h. Compression rate refers to the speed at which compressions are given, not thetotal number delivered in each minute. The number delivered is determined not onlyby the rate, but also by the number of interruptions to open the airway, deliver rescuebreaths, and allow AED analysis.

Compression-only CPR

Studies have shown that compression-only CPR may be as effective as combinedventilation and compression in the first few minutes after non-asphyxial arrest.However, chest compression combined with rescue breaths is the method of choicefor CPR by trained lay rescuers and professionals and should be the basis for lay-rescuer education. Lay rescuers who are unable or unwilling to provide rescuebreaths, should be encouraged to give chest compressions alone. When advisinguntrained laypeople by telephone, ambulance dispatchers should give instruction oncompression-only CPR.

Paediatric Basic Life Support (BLS)

Many children do not receive resuscitation because potential rescuers fear causingharm. This fear is unfounded; it is far better to use the adult BLS sequence forresuscitation of a child than to do nothing. For ease of teaching and retention,laypeople should be taught to use the adult sequence for children who are notresponsive and not breathing normally, with the single modification that the chestshould be compressed by one third of its depth. However, the following minormodifications to the adult sequence will make it even more suitable for use in

children:

Give 5 initial rescue breaths before starting chest compressions (adult BLSsequence of actions).

If you are on your own, perform CPR for 1 min before going for help.

Compress the chest by one third of its depth. Use two fingers for an infant under 1year; use one or two hands for a child over 1 year as needed to achieve an adequatedepth of compression.

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Adult Basic Life Support (BLS) Paediat ric BLS algorithmalgorithm

UNRESPONSIVE?

Shout for help

Open airway

Call 999

30 chest compressions

NOT BREATHINGNORMALLY?

2 rescue breaths30 compressions

UNRESPONSIVE?

Shout for help

Open airway

NOT BREATHINGNORMALLY?

If alone, perform 1 minute BLSas below prior to calling 999

5 initial rescue breaths and then30 chest compressions

2 rescue breaths30 compressions

Call 999 if not already done so

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Appendix 3

Defibrillation Guideline

Introduction

In the UK approximately 30,000 people sustain cardiac arrest outside hospital andare treated by emergency medical services (EMS) each year. Electrical defibrillationis well established as the only effective therapy for cardiac arrest caused byventricular fibrillation (VF) or pulseless ventricular tachycardia (VT). The scientificevidence to support early defibrillation is overwhelming; the delay from collapse todelivery of the first shock is the single most important determinant of survival. Ifdefibrillation is delivered promptly, survival rates as high as 75% have been reported.

The chances of successful defibrillation decline at a rate of about 10% with eachminute of delay; basic life support will help to maintain a shockable rhythm but is nota definitive treatment.

All AEDs analyse the victims ECG rhythm and determine the need for a shock. Thesemi-automatic AED indicates the need for a shock, which is delivered by theoperator, while the fully automatic AED administers the shock without the need forintervention by the operator.

Sequence of actions for AED

The following sequence applies to the use of both semi-automatic and automaticAEDsin a victim who is found to be unconscious and not breathing normally.

1. Follow the adult BLS sequence. Do not delay start ing CPR unless the AED isavailable immediately.

2. As soon as the AED arrives:

If more than one rescuer is present, continue CPR while the AED is switched on. Ifyou are alone, stop CPR and switch on the AED.

Follow the voice / visual prompts.

Attach the electrode pads to the patients bare chest.Ensure that nobody touches the victim while the AED is analysing the rhythm.

3A. If a shock is indicated:

Ensure that nobody touches the victim.

Push the shock button as directed (fully-automatic AEDs will deliver the shockautomatically).

Continue as directed by the voice / visual prompts.

Minimise, as far as possible, interruptions in chest compression.

3B. If no shock is indicated:Resume CPR immediately using a ratio of 30 compressions to 2 rescue breaths.

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Continue as directed by the voice / visual prompts.

4. Continue to follow the AED prompts until:

qualified help arrives and takes over OR

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

opening his/her eyes, speaking, or moving purposefully AND starts to breathenormally OR

you become exhausted.

Placement of AED pads

Place one AED pad to the right of the sternum (breast bone), below the clavicle(collar bone). Place the other pad in the left mid-axillary line, approximately over theposition of the V6 ECG electrode. It is important that this pad is placed sufficientlylaterally and that it is clear of any breast tissue.

Although most AED pads are labelled left and right, or carry a picture of their correctplacement, it does not matter if their positions are reversed. It is important to teachthat if this happens in error, the pads should not be removed and replaced becausethis wastes time and they may not adhere adequately when re-attached.

The victims chest must be sufficiently exposed to enable correct pad placement.Chest hair will prevent the pads adhering to the skin and will interfere with electricalcontact. Shave the chest only if the hair is excessive, and even then spend as littletime as possible on this. Do not delay defibrillation if a razor is not immediatelyavailable.

Defibri llation if the victim is wet

As long as there is no direct contact between the user and the victim when the shockis delivered, there is no direct pathway that the electricity can take that would causethe user to experience a shock. Dry the victims chest so that the adhesive AEDpads will stick and take particular care to ensure that no one is touching the victimwhen a shock is delivered.

Defibri llation in the presence of supplemental oxygen

There are no reports of fires caused by sparking where defibrillation was deliveredusing adhesive pads. If supplemental oxygen is being delivered by a face mask,remove the face mask and place it at least one metre away before delivering ashock. Do not allow this to delay shock delivery.

Minimise interruptions in CPR

The importance of early, uninterrupted chest compressions is emphasised. Interrupt

CPR only when it is necessary to analyse the rhythm and deliver a shock. When tworescuers are present, the rescuer operating the AED applies the electrodes while the

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other continues CPR. The AED operator delivers a shock as soon as the shock isadvised, ensuring that no one is in contact with the victim.

CPR before defibrillation

Provide good quality CPR while the AED is brought to the scene. Continue CPRwhilst the AED is turned on, then follow the voice and visual prompts. Giving aspecified period of CPR, as a routine before rhythm analysis and shock delivery, isnot recommended.

Voice prompts

The sequence of actions and voice prompts provided by an AED are usuallyprogrammable and it is recommended that they be set as follows:

deliver a single shock when a suitable rhythm is detected; no rhythm analysis immediately after the shock; a voice prompt for resumption of CPR immediately after the shock; a period of 2 min of CPR before further rhythm analysis.

AED use by healthcare profess ionals

All healthcare professionals should consider the use of an AED to be an integral

component of BLS. Early defibrillation should be available throughout all clinics.The Resuscitation Council (UK) advises that untrained employees working inhealthcare establishments not be prevented from using an AED if they areconfronted with a patient in cardiac arrest. The administration of a defibrillatory shockshould not be delayed while waiting for more highly trained personnel to arrive. Thesame principle should apply to individuals whose certified period of qualification hasexpired.

Storage and use of AEDs

AEDs should be stored in locations that are immediately accessible to rescuers; theyshould not be stored in locked cabinets as this may delay deployment. Use of the UKstandardised AED sign is encouraged, to highlight the location of an AED. Peoplewith no previous training have used AEDs safely and effectively. While it is highlydesirable that those who may be called upon to use an AED should be trained intheir use, and keep their skills up to date, circumstances can dictate that no trainedoperator (or a trained operator whose certificate of training has expired) is present atthe site of an emergency. Under these circumstances no inhibitions should be placedon any person willing to use an AED.

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Children

Standard AED pads are suitable for use in children older than 8 years. Specialpaediatric pads, that attenuate the current delivered during defibrillation, should beused in children aged between 1 and 8 years if they are available; if not, standard

adult-sized pads should be used. The use of an AED is not recommended in childrenaged less than 1 year. However, if an AED is the only defibrillator available its useshould be considered (preferably with the paediatric pads described above).

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AED algorithm

UNRESPONSIVE?

Open airwayNot breathing normally

CPR 30:2Until AED is attached

No shock advised

1 shock

Shock advised

Immediately resumeCPR 30:2 for 2 minutes

Call for help

Send or go for AEDCall 999

AEDassessesrhythm

Immediately resumeCPR 30:2 for 2 minutes

Continue until the victim starts

to wake up, i.e. moves, openseyes and breathes normally

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Appendix 4

BLS Required Equipment List

Automated Defibrillator (AED)Pocket Mask and one way valve.X 1 Spare AED BatteryX 2 Packets of Sealed PadsX 2 disposable razorsScissors to cut clothing if requiredGloves (Latex Free)

CL069

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Transcript of CL069