VOL: 102, ISSUE: 30, PAGE NO: 46
Phil Jevon, BSc, RN, PGCE, is resuscitation officer/clinical skills lead, Manor Hospital, Walsall; David Halliwell, MSc, is paramedic head of education, Dorset Ambulance NHS Trust.
Phil Jevon and David Halliwell outline the action that health professionals should take when cardiac arrest occurs in the community.
Revised guidelines on resuscitation were published in December 2005 by the Resuscitation Council (UK), the aim being to improve resuscitation practice and survival from cardiac arrest (www.resus.org.uk).
The changes are major and a period of transition is required for their implementation.
Guidance in 2001 from the Resuscitation Council (UK) made recommendations on the provision of resuscitation in the primary care setting (www.resus.org.uk). Included were recommendations on resuscitation equipment and resuscitation training (Resuscitation Council UK, 2001a).
Basic life support for adults
The sequence of actions for basic life support for adults is described in Box 1. To confirm that a person is having a cardiorespiratory arrest the nurse should look, listen, and feel for signs of normal breathing for no longer than 10 seconds. If the patient is not breathing normally, cardiopulmonary resuscitation (CPR) should be started (Resuscitation Council UK, 2005).
- Check for dangers, such as electricity and traffic, and ensure it is safe to approach the patient
- Check for response: gently shake the patient’s shoulders and ask: ‘Are you all right?’ If there is a response, leave the patient in the position in which she/he was found, if it is safe to do so. Try, then, to establish what is wrong and get help if required. If the patient does not respond, call out for help and turn the patient onto her/his back
- Open the patient’s airway: tilt the head and lift the chin (exercise caution if a cervical spine injury is suspected)
- Assess for signs of normal breathing
- Look, listen and feel for signs of normal breathing for no longer than 10 seconds: look for chest movement, listen at the patient’s mouth for breath sounds and feel for air on your cheek
- During the first few minutes following a cardiac arrest, agonal gasps (often seen as intermittent, deep sighing gasps) may be present, but these should not be confused with normal breathing. This breathing pattern is an indication to start cardio-pulmonary resuscitation immediately (Resuscitation Council UK, 2005)
- Place a patient who is breathing normally in the recovery position, and ensure help is called
- If the patient is not breathing normally, send someone to alert the emergency services (if alone, do this yourself) and then start CPR
- If appropriate, request an automated external defibrillator
- Start CPR: 30 chest compressions, then two ventilations (the ratio is 30:2)
Source: ResuscitationCouncil,UK, 2005
Checking for a carotid pulse to confirm a cardiac arrest is difficult and does not feature in the basic life support guidelines as it is an unreliable method of confirming the presence or absence of circulation (Bahr et al, 1997).
The observer should also ensure that the emergency services are alerted immediately and, if alone, should ask another person to do this before starting resuscitation (Resuscitation Council UK, 2005).
Chest compression technique is often poor, and unnecessary and lengthy interruptions to compressions are common (Abella et al, 2005). Several chest compressions are required to regain the coronary perfusion pressure before the interruption (Wik et al, 2005). The following technique will improve the delivery of chest compressions (Resuscitation Council UK, 2005):
- Adopt a system of 30 compressions to two ventilations (a 30:2 ratio), allowing more time for chest compressions at a rate of 100/minute (Chamberlain, 2005);
- When locating the correct position on the chest for compressions, position one hand in the centre of the chest and the other on top of it. Avoid applying pressure over the end of the sternum and the upper abdomen;
- If possible, the person performing the chest compressions should be changed approximately every two minutes so as to prevent fatigue.
Ventilations should have an inspiratory time of one second. This should be sufficient to achieve chest rise similar to that of normal breathing and minimise interruptions to the chest compressions (Resuscitation Council UK, 2005). Except in a minority of situations, for example, near drowning, the initial two ventilations before starting chest compressions are no longer recommended (Resuscitation Council UK, 2005).
It is important to avoid hyperventilation (too many breaths or too large a volume) as this can increase intrathoracic pressure, thus reducing venous return to the heart and diminishing cardiac output, in which case survival is reduced (Aufderheide et al, 2004). Hyperventilation can lead to gastric inflation, increasing the risk of regurgitation of
Automated external defibrillation
In the primary care setting, the most common cause of sudden cardiac death is ventricular fibrillation, the definitive treatment of which is early defibrillation. However, the chances of defibrillation being successful decline significantly each minute it is delayed. Public access to defibrillatorsand first responder schemes are now widespread. Nurses should consider the use of an automated external defibrillator as being part of their role (Resuscitation Council UK, 2005).
Chest compressions without ventilation
During the first few minutes following a cardiac arrest that has not been caused by asphyxia/hypoxia, the application of chest compressions only is just as effective as the application of chest compressions and ventilations (Resuscitation Council UK, 2005). The Council recommends that rescuers who are unable or unwilling to perform mouth-to-mouth ventilation should be encouraged to perform chest compressions only.
A nurse would be expected to perform effective CPR on patients, and generally should have an appropriate simple barrier device at hand, such as a pocket mask, so that ventilations can be performed.
Suspected cervical spine injury
If a cervical spine injury is suspected, for example, following a fall or a road traffic accident, the airway should be opened by lifting the chin but trying to avoid tilting the head, as this may aggravate the injury. However, opening the airway is the priority, and a degree of head tilt may be unavoidable (Resuscitation Council UK, 2005).
Basic life support for children
Children often do not receive CPR because potential rescuers are concerned that they may cause harm; however, this fear is unfounded and it is far better to adopt the adult sequence for basic life support than do nothing (Resuscitation Council UK, 2005). Nurses working in the community who have been taught basic life support for adults can therefore use the sequence that is recommended for adults, ideally with the following modifications (Resuscitation Council UK, 2005):
- Deliver five initial ventilations before starting chest compressions;
If alone, in most situations perform CPR first for one minute, then alert the emergency services;
Compress the chest approximately one-third of its depth using two fingers for an infant (< 1 year of age) and one or two hands for a child (> 1 year of age) as required to achieve adequate depth of compression.
Whenever possible, it is important to identify patients for whom cardiopulmonary arrest is a terminal event and those for whom resuscitation would be inappropriate. ‘Do Not attempt Resuscitation’ policies should be implemented following national guidelines (BMA et al, 2001) at, for example, community hospitals, hospices and nursing homes, and wherever the primary healthcare team is responsible for patient care (Resuscitation Council UK, 2001a).
Safe handling during resuscitation
Guidance for Safer Handling During Resuscitation in Hospitals (Resuscitation Council UK, 2001b) provides general guidance and advice on the safe handling of patients during cardiac arrest and cardiopulmonary resuscitation in hospitals. Many of the principles described also apply in primary care.
For further information on this issue see www.resus.org.uk.
All nurses who work in primary care could be required to perform CPR and some could be expected to use an automated external defibrillator. They should be aware of the principles of resuscitation in primary care.
Abella, B. et al (2005) Chest compression rates during cardiopulmonary resuscitation are suboptimal: a prospective study during in-hospital cardiac arrest. Circulation; 111: 4, 428-434
Aufderheide, T. et al (2004) Hyperventilation-induced hypotension during cardiopulmonary resuscitation Circulation; 109: 16, 1960-1965.
Bahr, J. et al (1997) Skills of lay people in checking the carotid pulse. Resuscitation; 35: 1, 23-26.
British Medical Association et al (2001) Decisions Relating to Cardiopulmonary Resuscitation. A Joint Statement from the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing. London: British Medical Association.
Chamberlain, D. (2005) New international consensus on cardiopulmonary resuscitation. British Medical Journal; 331: 7528, 1281-1282.
Resuscitation Council (UK) (2001a) Cardiopulmonary Resuscitation: Guidance for Clinical Practice and Training in Primary Care. London: Resuscitation Council UK.
Resuscitation Council (UK) (2001b) Guidance for Safer Handling During
Resuscitation in Hospitals. London: Resuscitation Council UK.
Resuscitation Council (UK) (2005) Resuscitation Guidelines 2005. London: Resuscitation Council UK.
Wik, L. et al (2005) Quality of cardiopulmonary resuscitation during out-of-hospital cardiac arrest. Journal of the American Medical Association; 293: 3, 299-304.