Professional Documents
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Aph
Aph
Preface
0300-9572/$ — see front matter © 2005 European Resuscitation Council. All Rights
Reserved. Published by Elsevier Ireland Ltd.
doi:10.1016/j.resuscitation.2005.10.001
S2
Preface
Perales (Spain), Gavin Perkins (UK), Sam Rich- bach (Germany), Christian
Torp Pederson (Den-
mond (UK), Antonio Rodriquez Nunez (Spain), Sten mark), Volker Wenzel
(Austria), Lars Wik (Norway),
Rubertsson (Sweden), Sebastian Russo (Germany), Benno Wolke (Germany),
Jonathan Wyllie (UK),
Jas Soar (UK), Eldar Soreide (Norway), Petter Steen David Zideman (UK).
(Norway), Benjamin Stenson (UK), Kjetil Sunde
Peter Baskett
(Norway), Caroline Telion (France), Andreas Thier-
David Zideman
Resuscitation (2005) 67S1, S7—S23
0300-9572/$ — see front matter © 2005 European Resuscitation Council. All Rights
Reserved. Published by Elsevier Ireland Ltd.
doi:10.1016/j.resuscitation.2005.10.007
S8
A.J. Handley et al.
Figure 2.4 Head tilt and chin lift. © 2005 European Figure 2.6 Look listen and
feel for normal breathing.
Resuscitation Council. © 2005 European
Resuscitation Council.
S10
A.J. Handley et al.
Figure 2.10 Interlock the fingers of your hands. © 2005 Figure 2.11 Press down on
the sternum 4—5 cm. © 2005
European Resuscitation Council. European Resuscitation
Council.
• If chest compressions only are given, these The jaw thrust is not
recommended for lay res-
should be continuous, at a rate of 100 min−1 . cuers because it is
difficult to learn and perform
• Stop to recheck the victim only if he starts and may itself cause
spinal movement.37 Therefore,
breathing normally; otherwise do not inter- the lay rescuer should
open the airway using a head
rupt resuscitation. tilt-chin lift
manoeuvre for both injured and non-
7 Continue resuscitation until injured victims.
• qualified help arrives and takes over
• the victim starts breathing normally Recognition of
cardiorespiratory arrest
• you become exhausted
Checking the carotid
pulse is an inaccurate
method of confirming
the presence or absence
Risk to the rescuer
of circulation.38
However, there is no evidence
The safety of both rescuer and victim are that checking for
movement, breathing or cough-
paramount during a resuscitation attempt. There ing (‘signs of a
circulation’) is diagnostically supe-
have been few incidents of rescuers suffering rior. Healthcare
professionals as well as lay rescuers
have difficulty
determining the presence or absence
of adequate or normal
breathing in unresponsive
victims.39,40 This may
be because the airway is
not open41 or because
the victim is making occa-
sional (agonal) gasps.
When bystanders are asked
by ambulance
dispatchers over the telephone if
breathing is present,
they often misinterpret agonal
gasps as normal
breathing. This erroneous informa-
tion can result in the
bystander withholding CPR
from a cardiac arrest
victim.42 Agonal gasps are
present in up to 40%
of cardiac arrest victims.
Bystanders describe
agonal gasps as barely breath-
ing, heavy or laboured
breathing, or noisy or gasp-
ing breathing.43
Laypeople should,
therefore, be taught to begin
CPR if the victim is
unconscious (unresponsive) and
not breathing
normally. It should be emphasised
during training that
agonal gasps occur commonly
Figure 2.14 Take your mouth away from the victim and in the first few
minutes after SCA. They are an indi-
watch for his chest to fall as air comes out. © 2005 Euro- cation for starting
CPR immediately and should not
pean Resuscitation Council. be confused with
normal breathing.
European Resuscitation Council Guidelines for Resuscitation 2005
S13
Foreign-body airway
obstruction (choking)
Foreign-body airway
obstruction (FBAO) is an
uncommon but potentially
treatable cause of acci-
dental death.88 Each
year approximately 16,000
adults and children in
the UK receive treatment in
an emergency department
for FBAO. Fortunately,
less than 1% of these
incidents are fatal.89 The
commonest cause of
choking in adults is airway
obstruction caused by
food such as fish, meat or
poultry.89 In infants
and children, half the reported
episodes of choking
occur while eating (mostly con-
fectionery), and the
remaining choking episodes
occur with non-food
items such as coins or toys.90
Deaths from choking are
rare in infants and chil-
Figure 2.17 With your other hand, grasp the far leg just dren; 24 deaths a year
on average were reported
above the knee and pull it up, keeping the foot on the in the UK between 1986
and 1995, and over half of
ground. © 2005 European Resuscitation Council. these children were
under 1 year.90
S16
A.J. Handley et al.
Table 2.1 Differentiation between mild and severe foreign body airway
obstruction (FBAO)a
Sign Mild obstruction
Severe obstruction
‘‘Are you choking?’’ ‘‘Yes’’
Unable to speak, may nod
Other signs Can speak, cough, breathe
Cannot breathe/wheezy breathing/silent
attempts to cough/unconsciousness
a General signs of FBAO: attack occurs while eating; victim may clutch at
neck.
No studies have evaluated the routine use of a finger • Give five initial rescue
breaths before starting
sweep to clear the airway in the absence of visible chest compressions (adult
sequence of actions,
airway obstruction,96—98 and four case reports have 5b).
S18
A.J. Handley et al.
• A lone rescuer should perform CPR for approxi- • push shock button as
directed (fully auto-
mately 1 min before going for help. matic AEDs will
deliver the shock automat-
• Compress the chest by approximately one third ically)
of its depth; use two fingers for an infant under • continue as directed
by the voice/visual
1 year; use one or two hands for a child over 1 prompts
year as needed to achieve an adequate depth of 5b If no shock indicated
compression. • immediately resume
CPR, using a ratio of 30
compressions to 2
rescue breaths
The same modifications of five initial breaths, and • continue as directed
by the voice/visual
1 min of CPR by the lone rescuer before getting prompts
help, may improve outcome for victims of drown- 6 Continue to follow the
AED prompts until
ing. This modification should be taught only to • qualified help arrives
and takes over
those who have a specific duty of care to poten- • the victim starts to
breathe normally
tial drowning victims (e.g. lifeguards). Drowning is • you become exhausted
easily identified. It can be difficult, on the other
hand, for a layperson to determine whether car-
diorespiratory arrest is a direct result of trauma CPR before defibrillation
or intoxication. These victims should, therefore, be
managed according to the standard protocol. Immediate defibrillation, as
soon as an AED
becomes available, has
always been a key ele-
ment in guidelines and
teaching, and considered of
Use of an automated external paramount importance for
survival from ventricu-
defibrillator lar fibrillation. This
concept has been challenged
because evidence suggests
that a period of chest
Section 3 discusses the guidelines for defibrillation compression before
defibrillation may improve sur-
using both automated external defibrillators (AEDs) vival when the time between
calling for the ambu-
and manual defibrillators. However, there are some lance and its arrival
exceeds 5 min.28,61,100 One
special considerations when an AED is to be used by study101 did not confirm
this benefit, but the weight
lay or non-healthcare rescuers. of evidence supports a
period of CPR for victims of
Standard AEDs are suitable for use in children prolonged cardiac arrest
before defibrillation.
older than 8 years. For children between 1 and 8 In all of these studies
CPR was performed by
years use paediatric pads or a paediatric mode if paramedics, who protected
the airway by intuba-
available; if these are not available, use the AED as tion and delivered 100%
oxygen. Such high-quality
it is. Use of AEDs is not recommended for children ventilation cannot be
expected from lay rescuers
less than 1 year. giving mouth-to-mouth
ventilation. Secondly, the
benefit from CPR occurred
only when the delay from
Sequence for use of an AED call to the availability of
a defibrillator was greater
than 5 min; the delay from
collapse to arrival of the
See Figure 2.20. rescuer with an AED will
rarely be known with cer-
tainty. Thirdly, if good
bystander CPR is already in
(1) Make sure you, the victim, and any bystanders progress when the AED
arrives, it does not seem
are safe. logical to continue it any
further. For these reasons
(2) If the victim is unresponsive and not breathing these guidelines recommend
an immediate shock,
normally, send someone for the AED and to call as soon as the AED is
available. The importance of
for an ambulance. early uninterrupted
external chest compression is
(3) Start CPR according to the guidelines for BLS. emphasised.
(4) As soon as the defibrillator arrives
• switch on the defibrillator and attach the
electrode pads. If more than one rescuer is Voice prompts
present, CPR should be continued while this
is carried out In several places, the
sequence of actions states
• follow the spoken/visual directions ‘follow the voice/visual
prompts’. The prompts are
• ensure that nobody touches the victim while usually programmable, and
it is recommended that
the AED is analysing the rhythm they be set in accordance
with the sequence of
5a If a shock is indicated shocks and timings for CPR
given in Section 2. These
• ensure that nobody touches the victim should include at least:
European Resuscitation Council Guidelines for Resuscitation 2005
S19
(1) a single shock only, when a shockable rhythm is input from the rescuer.
One manikin study showed
detected that untrained nursing
students committed fewer
(2) no rhythm check, or check for breathing or a safety errors using a
fully-automatic AED rather
pulse, after the shock than a semi-automatic
AED.102 There are no human
(3) a voice prompt for immediate resumption of data to determine whether
these findings can be
CPR after the shock (giving chest compressions applied to clinical use.
in the presence of a spontaneous circulation is
not harmful)
Public access
defibrillation programmes
(4) two minutes for CPR before a prompt to assess
the rhythm, breathing or a pulse is given Public access
defibrillation (PAD) and first responder
AED programmes may
increase the number of vic-
The shock sequence and energy levels are dis-
tims who receive bystander
CPR and early defibril-
cussed in Section 3.
lation, thus improving
survival from out-of-hospital
SCA.103 These programmes
require an organised
Fully-automatic AEDs and practised response
with rescuers trained and
equipped to recognise
emergencies, activate the
Having detected a shockable rhythm, a fully- EMS system, provide CPR
and use the AED.104,105 Lay
automatic AED will deliver a shock without further rescuer AED programmes
with very rapid response
S20
A.J. Handley et al.
0300-9572/$ — see front matter © 2005 European Resuscitation Council. All Rights
Reserved. Published by Elsevier Ireland Ltd.
doi:10.1016/j.resuscitation.2005.10.002
S4
Jerry Nolan
0300-9572/$ — see front matter © 2005 European Resuscitation Council. All Rights
Reserved. Published by Elsevier Ireland Ltd.
doi:10.1016/j.resuscitation.2005.10.008
S26
C.D. Deakin, J.P. Nolan
significant burns to the patient. The risk of fire dur- Shaving the chest
ing attempted defibrillation can be minimised by
taking the following precautions. Patients with a hairy
chest have air trapping
beneath the electrode and
poor electrode-to-skin
• Take off any oxygen mask or nasal cannulae and electrical contact. This
causes high impedance,
place them at least 1 m away from the patient’s reduced defibrillation
efficacy, risk of arcing
chest. (sparks) from electrode
to skin and electrode
• Leave the ventilation bag connected to the tra- to electrode and is more
likely to cause burns
cheal tube or other airway adjunct. Alterna- to the patient’s chest.
Rapid shaving of the
tively, disconnect any bag-valve device from the area of intended
electrode placement may be
tracheal tube (or other airway adjunct such as necessary, but do not
delay defibrillation if a
the laryngeal mask airway, combitube or laryn- shaver is not immediately
available. Shaving the
geal tube), and remove it at least 1 m from the chest per se may reduce
transthoracic impedance
patient’s chest during defibrillation. slightly and has been
recommended for elective DC
• If the patient is connected to a ventilator, for cardioversion.35
example in the operating room or critical care
unit, leave the ventilator tubing (breathing cir-
Paddle force
cuit) connected to the tracheal tube unless chest
compressions prevent the ventilator from deliv- If using paddles, apply
them firmly to the chest
ering adequate tidal volumes. In this case, the wall. This reduces
transthoracic impedance by
ventilator is usually substituted for a ventila- improving electrical
contact at the electrode—skin
tion bag, which can itself be left connected or interface and reducing
thoracic volume.36 The
detached and removed to a distance of at least defibrillator operator
should always press firmly
1 m. If the ventilator tubing is disconnected, on handheld electrode
paddles, the optimal force
ensure it is kept at least 1 m from the patient being 8 kg in adults37
and 5 kg in children aged
or, better still, switch the ventilator off; mod- 1—8 years when using
adult paddles38 ; 8-kg force
ern ventilators generate massive oxygen flows may be attainable only by
the strongest mem-
when disconnected. During normal use, when bers of the cardiac
arrest team, and therefore it
connected to a tracheal tube, oxygen from a ven- is recommended that these
individuals apply the
tilator in the critical care unit will be vented from paddles during
defibrillation. Unlike self-adhesive
the main ventilator housing well away from the pads, manual paddles have
a bare metal plate that
defibrillation zone. Patients in the critical care requires a conductive
material placed between the
unit may be dependent on positive end expiratory metal and patient’s skin
to improve electrical con-
pressure (PEEP) to maintain adequate oxygena- tact. Use of bare metal
paddles alone creates high
tion; during cardioversion, when the spontaneous transthoracic impedance
and is likely to increase
circulation potentially enables blood to remain the risk of arcing and to
worsen cutaneous burns
well oxygenated, it is particularly appropriate to from defibrillation.
leave the critically ill patient connected to the
ventilator during shock delivery.
Electrode position
• Minimise the risk of sparks during defibrillation.
Theoretically, self-adhesive defibrillation pads No human studies have
evaluated the electrode
are less likely to cause sparks than manual pad- position as a determinant
of return of spontaneous
dles. circulation (ROSC) or
survival from VF/VT cardiac
arrest. Transmyocardial
current during defibrilla-
The technique for electrode contact with tion is likely to be
maximal when the electrodes
the chest are placed so that the
area of the heart that is fib-
rillating lies directly
between them, i.e., ventricles
Optimal defibrillation technique aims to deliver in VF/VT, atria in atrial
fibrillation (AF). Therefore,
current across the fibrillating myocardium in the the optimal electrode
position may not be the same
presence of minimal transthoracic impedance. for ventricular and
atrial arrhythmias.
Transthoracic impedance varies considerably with More patients are
presenting with implantable
body mass, but is approximately 70—80 # in medical devices (e.g.,
permanent pacemaker,
adults.33,34 The techniques described below aim to automatic implantable
cardioverter defibrillator
place external electrodes (paddles or self-adhesive (AICD)). MedicAlert
bracelets are recommended for
pads) in an optimal position using techniques that such patients. These
devices may be damaged dur-
minimise transthoracic impedance. ing defibrillation if
current is discharged through
S28
C.D. Deakin, J.P. Nolan
and providers are familiar with the devices they use Blind defibrillation
in clinical care, there will be no need for the default
200 J dose. Ongoing research is necessary to firmly Delivery of shocks
without a monitor or an ECG
establish the most appropriate initial settings for rhythm diagnosis is
referred to as ‘‘blind’’ defibril-
both monophasic and biphasic defibrillators. lation. Blind
defibrillation is unnecessary. Handheld
paddles with ‘‘quick-
look’’ monitoring capabilities
Second and subsequent shocks on modern manually
operated defibrillators are
widely available. AEDs
use reliable and proven deci-
With monophasic defibrillators, if the initial shock sion algorithms to
identify VF.
has been unsuccessful at 360 J, second and sub-
sequent shocks should all be delivered at 360 J. Spurious asystole and
occult ventricular
With biphasic defibrillators there is no evidence to fibrillation
support either a fixed or escalating energy proto-
col. Both strategies are acceptable; however, if the Rarely, coarse VF can be
present in some leads, with
first shock is not successful and the defibrillator is very small undulations
seen in the orthogonal leads,
capable of delivering shocks of higher energy, it which is called occult
VF. A flat line that may resem-
is rational to increase the energy for subsequent ble asystole is
displayed; examine the rhythm in
shocks. If the provider is unaware of the effective two leads to obtain the
correct diagnosis. Of more
dose range of the biphasic device and has used the importance, one study
noted that spurious asystole,
default 200 J dose for the first shock, use either a flat line produced by
technical errors (e.g., no
an equal or higher dose for second or subsequent power, leads unconnected,
gain set to low, incor-
shocks, depending on the capabilities of the device. rect lead selection, or
polarisation of electrolyte
If a shockable rhythm (recurrent ventricular fib- gel (see above)), was far
more frequent than occult
rillation) recurs after successful defibrillation (with VF.120
or without ROSC), give the next shock with the There is no evidence
that attempting to defib-
energy level that had previously been successful. rillate true asystole is
beneficial. Studies in
children121 and adults122
have failed to show bene-
fit from defibrillation of
asystole. On the contrary,
Other related defibrillation topics repeated shocks will
cause myocardial injury.
most likely to occur when the patient is monitored. randomised study comparing
escalating monophasic
Precordial thump should be undertaken immedi- energy levels to 360 J and
biphasic energy levels to
ately after confirmation of cardiac arrest and only 200 J found no difference
in efficacy between the
by healthcare professionals trained in the tech- two waveforms.137 An
initial shock of 120—150 J,
nique. Using the ulnar edge of a tightly clenched escalating if necessary,
is a reasonable strategy
fist, a sharp impact is delivered to the lower half of based on current data.
the sternum from a height of about 20 cm, followed
by immediate retraction of the fist, which creates Atrial flutter and
paroxysmal
an impulse-like stimulus. supraventricular
tachycardia
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nonparametric classification of ventricular fibrillation
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tion: a randomized, controlled swine study. Ann Emerg Med 98. Morrison
LJ, Dorian P, Long J, et al. Out-of-hospital car-
2002;40:563—70. diac
arrest rectilinear biphasic to monophasic damped sine
82. Berg RA, Hilwig RW, Ewy GA, Kern KB. Precountershock
defibrillation waveforms with advanced life support inter-
cardiopulmonary resuscitation improves initial response vention
trial (ORBIT). Resuscitation 2005;66:149—57.
to defibrillation from prolonged ventricular fibrillation: 99. Kerber RE,
Martins JB, Kienzle MG, et al. Energy, current,
a randomized, controlled swine study. Crit Care Med and
success in defibrillation and cardioversion: clinical
2004;32:1352—7. studies
using an automated impedance-based method of
83. Kolarova J, Ayoub IM, Yi Z, Gazmuri RJ. Optimal timing for energy
adjustment. Circulation 1988;77:1038—46.
electrical defibrillation after prolonged untreated ventric- 100. Koster RW,
Dorian P, Chapman FW, Schmitt PW, O’Grady
ular fibrillation. Crit Care Med 2003;31:2022—8. SG, Walker
RG. A randomized trial comparing monophasic
84. Berg RA, Sanders AB, Kern KB, et al. Adverse hemo- and
biphasic waveform shocks for external cardioversion of
dynamic effects of interrupting chest compressions for atrial
fibrillation. Am Heart J 2004;147:e20.
rescue breathing during cardiopulmonary resuscitation 101. Martens
PR, Russell JK, Wolcke B, et al. Optimal Response
for ventricular fibrillation cardiac arrest. Circulation to Cardiac
Arrest study: defibrillation waveform effects.
2001;104:2465—70.
Resuscitation 2001;49:233—43.
85. Kern KB, Hilwig RW, Berg RA, Sanders AB, Ewy GA. 102. Weaver WD,
Cobb LA, Copass MK, Hallstrom AP. Ventricu-
Importance of continuous chest compressions during lar
defibrillation: a comparative trial using 175-J and 320-J
cardiopulmonary resuscitation: improved outcome dur- shocks. N
Engl J Med 1982;307:1101—6.
ing a simulated single lay-rescuer scenario. Circulation 103. Tang W,
Weil MH, Sun S, et al. The effects of
2002;105:645—9. biphasic
and conventional monophasic defibrillation on
86. Yu T, Weil MH, Tang W, et al. Adverse outcomes of inter-
postresuscitation myocardial function. J Am Coll Cardiol
rupted precordial compression during automated defibril-
1999;34:815—22.
lation. Circulation 2002;106:368—72. 104. Gliner BE,
Jorgenson DB, Poole JE, et al. Treatment of out-
87. Eftestol T, Sunde K, Steen PA. Effects of interrupting pre- of-
hospital cardiac arrest with a low-energy impedance-
cordial compressions on the calculated probability of defib-
compensating biphasic waveform automatic external defib-
rillation success during out-of-hospital cardiac arrest. Cir- rillator.
The LIFE Investigators. Biomed Instrum Technol
culation 2002;105:2270—3.
1998;32:631—44.
88. Valenzuela TD, Kern KB, Clark LL, et al. Interruptions 105. White RD,
Blackwell TH, Russell JK, Snyder DE, Jorgenson
of chest compressions during emergency medical systems DB.
Transthoracic impedance does not affect defibrillation,
resuscitation. Circulation 2005;112:1259—65.
resuscitation or survival in patients with out-of-hospital
89. van Alem AP, Sanou BT, Koster RW. Interruption of car- cardiac
arrest treated with a non-escalating biphasic wave-
diopulmonary resuscitation with the use of the automated form
defibrillator. Resuscitation 2005;64:63—9.
external defibrillator in out-of-hospital cardiac arrest. Ann 106. Kuisma M,
Suominen P, Korpela R. Paediatric out-of-hospital
Emerg Med 2003;42:449—57. cardiac
arrests: epidemiology and outcome. Resuscitation
90. Bain AC, Swerdlow CD, Love CJ, et al. Multicenter study
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PE, Pepe PE, Shook JE, et al. A prospective,
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91. Poole JE, White RD, Kanz KG, et al. Low-energy impedance- ology,
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compensating biphasic waveforms terminate ventricular pediatric
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1999;33:174—84.
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Cohen DM, Strausbaugh S, Dietrich AM. Pedi-
1997;8:1373—85. atric
patients requiring CPR in the prehospital setting. Ann
92. Schneider T, Martens PR, Paschen H, et al. Multicenter, Emerg Med
1995;25:495—501.
randomized, controlled trial of 150-J biphasic shocks com- 109. Appleton
GO, Cummins RO, Larson MP, Graves JR. CPR and
pared with 200- to 360-J monophasic shocks in the resusci- the single
rescuer: at what age should you ‘‘call first’’
tation of out-of-hospital cardiac arrest victims. Optimized rather
than ‘‘call fast’’? Ann Emerg Med 1995;25:492—4.
Response to Cardiac Arrest (ORCA) Investigators. Circula- 110. Ronco R,
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European Resuscitation Council Guidelines for Resuscitation 2005
S37
0300-9572/$ — see front matter © 2005 European Resuscitation Council. All Rights
Reserved. Published by Elsevier Ireland Ltd.
doi:10.1016/j.resuscitation.2005.10.009
S40
J.P. Nolan et al.
and pulseless electrical activity (PEA)). The prin- discharge after cardiac
arrest, although they are
cipal difference in the management of these two still included among ALS
interventions. Thus, during
groups of arrhythmias is the need for attempted advanced life support,
attention must be focused
defibrillation in those patients with VF/VT. Subse- on early defibrillation and
high-quality, uninter-
quent actions, including chest compressions, air- rupted BLS.
way management and ventilation, venous access,
administration of adrenaline and the identification Shockable rhythms
(ventricular
and correction of reversible factors, are common to
fibrillation/pulseless
ventricular
both groups.
tachycardia)
Although the ALS cardiac arrest algorithm
(Figure 4.2) is applicable to all cardiac arrests, In adults, the commonest
rhythm at the time of
additional interventions may be indicated for car- cardiac arrest is VF,
which may be preceded by a
diac arrest caused by special circumstances (Sec- period of VT or even
supraventricular tachycardia
tion 7). (SVT).67 Having confirmed
cardiac arrest, summon
The interventions that unquestionably con- help (including the
request for a defibrillator) and
tribute to improved survival after cardiac arrest are start CPR, beginning with
external chest compres-
early defibrillation for VF/VT and prompt and effec- sion, with a
compression:ventilation (CV) ratio of
tive bystander basic life support (BLS). Advanced 30:2. As soon as the
defibrillator arrives, diagnose
airway intervention and the delivery of drugs have the rhythm by applying
paddles or self-adhesive
not been shown to increase survival to hospital pads to the chest.
S46
J.P. Nolan et al.
and has adequate ongoing experience with the route for vascular access in
children, it can also be
technique. Personnel skilled in advanced airway effective in adults.78
Intraosseous injection of drugs
management should attempt laryngoscopy with- achieves adequate plasma
concentrations in a time
out stopping chest compressions; a brief pause in comparable with injection
through a central venous
chest compressions may be required as the tube catheter. The intraosseous
route also enables with-
is passed through the vocal cords. Alternatively, to drawal of marrow for venous
blood gas analysis and
avoid any interruptions in chest compressions, the measurement of electrolytes
and haemoglobin con-
intubation attempt may be deferred until return centration.
of spontaneous circulation. No intubation attempt
should take longer than 30 s: if intubation has not Tracheal route. If neither
intravenous nor
been achieved after this time, recommence bag- intraosseous access can be
established, some
mask ventilation. After intubation, confirm cor- drugs can be given by the
tracheal route. How-
rect tube position and secure it adequately. Once ever, unpredictable plasma
concentrations are
the patient’s trachea has been intubated, con- achieved when drugs are
given via a tracheal tube,
tinue chest compressions, at a rate of 100 min−1 , and the optimal tracheal
dose of most drugs is
without pausing during ventilation. Ventilate the unknown. During CPR, the
equipotent dose of
lungs at 10 breaths min−1 ; do not hyperventilate adrenaline given via the
trachea is three to ten
the patient. A pause in the chest compressions times higher than the
intravenous dose.79,80 Some
allows the coronary perfusion pressure to fall sub- animal studies suggest that
the lower adrenaline
stantially. On resuming compressions there is some concentrations achieved when
the drug is given via
delay before the original coronary perfusion pres- the trachea may produce
transient beta-adrenergic
sure is restored, thus chest compressions that are effects, which will cause
hypotension and lower
not interrupted for ventilation result in a substan- coronary artery perfusion
pressure.81—84 If given
tially higher mean coronary perfusion pressure. via the trachea, the dose of
adrenaline is 3 mg
In the absence of personnel skilled in tracheal diluted to at least 10 ml
with sterile water. Dilution
intubation, acceptable alternatives are the Com- with water instead of 0.9%
saline may achieve
bitube, laryngeal mask airway (LMA), ProSeal LMA, better drug absorption.85
The solutions in prefilled
or Laryngeal Tube (Section 4d). Once one of these syringes are acceptable for
this purpose.
airways has been inserted, attempt to deliver con- Adrenaline. Despite the
widespread use of
tinuous chest compressions, uninterrupted during adrenaline during
resuscitation, and several
ventilation. If excessive gas leakage causes inade- studies involving
vasopressin, there is no placebo-
quate ventilation of the patient’s lungs, chest com- controlled study that shows
that the routine use of
pressions will have to be interrupted to enable ven- any vasopressor at any stage
during human cardiac
tilation (using a CV ratio of 30:2). arrest increases survival to
hospital discharge. Cur-
During continuous chest compressions, ventilate rent evidence is insufficient
to support or refute
the lungs at 10 breaths min−1 . the routine use of any
particular drug or sequence
of drugs. Despite the lack
of human data, the use
Intravenous access and drugs of adrenaline is still
recommended, based largely
on animal data. The alpha-
adrenergic actions of
Peripheral versus central venous drug delivery. adrenaline cause
vasoconstriction, which increases
Establish intravenous access if this has not already myocardial and cerebral
perfusion pressure. The
been achieved. Although peak drug concentrations higher coronary blood flow
increases the frequency
are higher and circulation times are shorter when of the VF waveform and
should improve the chance
drugs are injected into a central venous catheter of restoring a circulation
when defibrillation is
compared with a peripheral cannula,77 insertion of attempted.86—88 The optimal
duration of CPR and
a central venous catheter requires interruption of number of shocks that should
be given before
CPR and is associated with several complications. giving drugs is unknown. On
the basis of expert
Peripheral venous cannulation is quicker, easier to consensus, if VF/VT persists
after two shocks,
perform and safer. Drugs injected peripherally must give adrenaline and repeat
every 3—5 min during
be followed by a flush of at least 20 ml of fluid and cardiac arrest. Do not
interrupt CPR to give drugs.
elevation of the extremity for 10—20 s to facilitate
drug delivery to the central circulation. Anti-arrhythmic drugs. There
is no evidence that
giving any anti-arrhythmic
drug routinely dur-
Intraosseous route. If intravenous access is diffi- ing human cardiac arrest
increases survival to
cult or impossible, consider the intraosseous route. hospital discharge. In
comparison with placebo89
Although normally considered as an alternative and lidocaine,90 the use of
amiodarone in shock-
S48
J.P. Nolan et al.
In a patient who is
making respiratory efforts,
complete airway
obstruction causes paradoxical
chest and abdominal
movement, often described
as ‘see-saw breathing’. As
the patient attempts to
breathe in, the chest is
drawn in and the abdomen
expands; the opposite
occurs during expiration.
This is in contrast to the
normal breathing pattern
of synchronous movement
upwards and outwards
of the abdomen (pushed
down by the diaphragm)
with the lifting of the
chest wall. During airway
obstruction, other
accessory muscles of respiration
are used, with the neck
and the shoulder mus-
cles contracting to assist
movement of the tho-
racic cage. Full
examination of the neck, chest and
abdomen is required to
differentiate the paradox-
ical movements that may
mimic normal respira-
tion. The examination must
include listening for
the absence of breath
sounds in order to diagnose
complete airway
obstruction reliably; any noisy
breathing indicates
partial airway obstruction. Dur-
ing apnoea, when
spontaneous breathing move-
ments are absent, complete
airway obstruction is
recognised by failure to
inflate the lungs during
attempted positive
pressure ventilation. Unless air-
way patency can be re-
established to enable ade-
quate lung ventilation
within a period of a very few
minutes, neurological and
other vital organ injury
may occur, leading to
cardiac arrest.
Figure 4.3 Causes of airway obstruction.
Basic airway management
mon, but may arise from excessive bronchial secre-
tions, mucosal oedema, bronchospasm, pulmonary Once any degree of
obstruction is recognised,
oedema or aspiration of gastric contents. immediate measures must be
taken to create and
maintain a clear airway.
There are three manoeu-
Recognition of airway obstruction vres that may improve the
patency of an airway
obstructed by the tongue
or other upper airway
Airway obstruction can be subtle and is often missed structures: head tilt,
chin lift, and jaw thrust.
by healthcare professionals, let alone by lay peo-
ple. The ‘look, listen and feel’ approach is a simple, Head tilt and chin lift
systematic method of detecting airway obstruction.
The rescuer’s hand is
placed on the patient’s fore-
• Look for chest and abdominal movements. head and the head gently
tilted back; the fingertips
• Listen and feel for airflow at the mouth and nose. of the other hand are
placed under the point of the
In partial airway obstruction, air entry is dimin- patient’s chin, which is
gently lifted to stretch the
ished and usually noisy. Inspiratory stridor is caused anterior neck structures
(Figure 4.4).100—105
by obstruction at the laryngeal level or above. Expi-
ratory wheeze implies obstruction of the lower air- Jaw thrust
ways, which tend to collapse and obstruct during
expiration. Other characteristic sounds include the Jaw thrust is an
alternative manoeuvre for bringing
following: the mandible forward and
relieving obstruction by
the soft palate and
epiglottis. The rescuer’s index
• Gurgling is caused by liquid or semisolid foreign and other fingers are
placed behind the angle of
material in the main airways. the mandible, and pressure
is applied upwards and
• Snoring arises when the pharynx is partially forwards. Using the
thumbs, the mouth is opened
occluded by the soft palate or epiglottis. slightly by downward
displacement of the chin
• Crowing is the sound of laryngeal spasm. (Figure 4.5).
European Resuscitation Council Guidelines for Resuscitation 2005
S51
Airway management in
patients with suspected
cervical spine injury
If spinal injury is
suspected (e.g., if the victim has
fallen, been struck on the
head or neck, or has been
rescued after diving into
shallow water), maintain
the head, neck, chest and
lumbar region in the neu-
tral position during
resuscitation. Excessive head
tilt could aggravate the
injury and damage the cer-
vical spinal cord106—110 ;
however, this complication
has not been documented
and the relative risk is
unknown. When there is a
risk of cervical spine
injury, establish a clear
upper airway by using jaw
thrust or chin lift in
combination with manual in-
line stabilisation (MILS)
of the head and neck by an
assistant.111,112 If life-
threatening airway obstruc-
tion persists despite
effective application of jaw
thrust or chin lift, add
head tilt a small amount
at a time until the airway
is open; establishing a
patent airway takes
priority over concerns about a
potential cervical spine
injury.
an adequate volume,
minimising the risk of gas-
tric inflation, and allowing
adequate time for chest
compressions. During CPR
with an unprotected air-
way, give two ventilations
after each sequence of
30 chest compressions.
Self-inflating bag
LMA during cardiac arrest reduces the incidence of may be one of the main
benefits of a tracheal tube.
regurgitation.127 There are remarkably few
cases of pulmonary aspi-
In comparison with tracheal intubation, the per- ration reported in the
studies of the LMA during
ceived disadvantages of the LMA are the increased CPR.
risk of aspiration and inability to provide adequate
ventilation in patients with low lung and/or chest- The Combitube
wall compliance. There are no data demonstrating
whether or not it is possible to provide adequate The Combitube is a double-
lumen tube intro-
ventilation via an LMA without interruption of chest duced blindly over the
tongue, and provides a
compressions. The ability to ventilate the lungs route for ventilation
whether the tube has passed
adequately while continuing to compress the chest into the oesophagus
(Figure 4.10a) or the tra-
Figure 4.10 (a) Combitube in the oesophageal position. (b) Combitube in the
tracheal position. © 2005 European
Resuscitation Council.
S56
J.P. Nolan et al.
The recommended adult dose of atropine for not give calcium solutions
and sodium bicarbonate
asystole or PEA with a rate <60 min−1 is 3 mg intra- simultaneously by the same
route.
venously in a single bolus. Its use in the treatment
of bradycardia is covered in Section 4f. Several Buffers. Cardiac arrest
results in combined res-
recent studies have failed to demonstrate any ben- piratory and metabolic
acidosis caused by cessa-
efit from atropine in out-of-hospital or in-hospital tion of pulmonary gas
exchange and the devel-
cardiac arrests174,206—210 ; however, asystole carries opment of anaerobic
cellular metabolism, respec-
a grave prognosis and there are anecdotal accounts tively. The best treatment
of acidaemia in cardiac
of success after giving atropine. It is unlikely to be arrest is chest
compression; some additional ben-
harmful in this situation. efit is gained by
ventilation. If the arterial blood
pH is less than 7.1 (or
base excess more negative
Theophylline (aminophylline). Theophylline is a than −10 mmol l−1 ) during
or following resuscita-
phosphodiesterase inhibitor that increases tissue tion from cardiac arrest,
consider giving small doses
concentrations of cAMP and releases adrenaline of sodium bicarbonate (50
ml of an 8.4% solution).
from the adrenal medulla. It has chronotropic and During cardiac arrest,
arterial gas values may be
inotropic actions. The limited studies of amino- misleading and bear little
relationship to the tissue
phylline in bradyasystolic cardiac arrest have failed acid—base state96 ;
analysis of central venous blood
to demonstrate an increase in ROSC or survival to may provide a better
estimation of tissue pH (see
hospital discharge211—214 ; the same studies have Section 4c). Bicarbonate
causes generation of car-
not shown that harm is caused by aminophylline. bon dioxide, which
diffuses rapidly into cells. This
Aminophylline is indicated in: has the following effects.
• asystolic cardiac arrest • It exacerbates
intracellular acidosis.
• peri-arrest bradycardia refractory to atropine • It produces a negative
inotropic effect on
ischaemic myocardium.
Theophylline is given as aminophylline, a mix- • It presents a large,
osmotically active, sodium
ture of theophylline with ethylenediamine, which is load to an already
compromised circulation and
20 times more soluble than theophylline alone. The brain.
recommended adult dose is 250—500 mg (5 mg kg−1 ) • It produces a shift to
the left in the oxygen disso-
given by slow intravenous injection. ciation curve, further
inhibiting release of oxygen
Theophylline has a narrow therapeutic win- to the tissues.
dow with an optimal plasma concentration of
10—20 mg l−1 (55—110 mmol l−1 ). Above this con- Mild acidaemia causes
vasodilation and can
centration, side effects such as arrhythmias and increase cerebral blood
flow. Therefore, full cor-
convulsions may occur, especially when given rection of the arterial
blood pH may theoretically
rapidly by intravenous injection. reduce cerebral blood flow
at a particularly critical
time. As the bicarbonate
ion is excreted as car-
Calcium. Calcium plays a vital role in the cellu- bon dioxide via the lungs,
ventilation needs to be
lar mechanisms underlying myocardial contraction. increased. For all these
reasons, metabolic acidosis
There are very few data supporting any benefi- must be severe to justify
giving sodium bicarbon-
cial action for calcium after most cases of car- ate.
diac arrest. High plasma concentrations achieved Several animal and
clinical studies have exam-
after injection may be harmful to the ischaemic ined the use of buffers
during cardiac arrest. Clin-
myocardium and may impair cerebral recovery. ical studies using
Tribonate®215 or sodium bicar-
Give calcium during resuscitation only when indi- bonate as buffers have
failed to demonstrate any
cated specifically, i.e. in pulseless electrical activ- advantage.216—220 Only one
study has found clinical
ity caused by benefit, suggesting that
EMS systems using sodium
• hyperkalaemia bicarbonate earlier and
more frequently had sig-
• hypocalcaemia nificantly higher ROSC and
hospital discharge rates
• overdose of calcium channel-blocking drugs and better long-term
neurological outcome.221 Ani-
mal studies have generally
been inconclusive, but
The initial dose of 10 ml 10% calcium chloride some have shown benefit in
giving sodium bicarbon-
(6.8 mmol Ca2+ ) may be repeated if necessary. ate to treat
cardiovascular toxicity (hypotension,
Calcium can slow the heart rate and precipitate cardiac arrhythmias)
caused by tricyclic antidepres-
arrhythmias. In cardiac arrest, calcium may be sants and other fast
sodium channel blockers (Sec-
given by rapid intravenous injection. In the pres- tion 7b).222 Giving sodium
bicarbonate routinely
ence of a spontaneous circulation give it slowly. Do during cardiac arrest and
CPR (especially in out-
European Resuscitation Council Guidelines for Resuscitation 2005
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European Resuscitation Council Guidelines for Resuscitation 2005
S85
Introduction Acute
coronary syndromes are the commonest
cause of
malignant arrhythmias leading to sudden
The incidence of acute myocardial infarction cardiac death.
The therapeutic goals are to treat
(AMI) is decreasing in many European countries.1 acute life-
threatening conditions, such as ventricu-
Although in-hospital mortality from AMI has been lar fibrillation
(VF) or extreme bradycardias, and to
reduced significantly by modern reperfusion ther- preserve left
ventricular function and prevent heart
apy and improved secondary prophylaxis,1 the over- failure by
minimising the extent of any myocar-
all 28-day mortality is virtually unchanged because dial infarction.
These guidelines address the first
about two thirds of those that die do so before hours after
onset of symptoms. Out-of-hospital
arrival at hospital.2 Thus, the best chance of treatment and
initial therapy in the emergency
improving survival after AMI is by improving treat- department may
vary according to local capabili-
ment in the early, and particularly the out-of hos- ties, resources
and regulations. The data supporting
pital, phase of the disease. out-of-hospital
treatment are usually extrapolated
The term acute coronary syndrome (ACS) encom- from studies of
initial treatment early after hospital
passes three different entities within the acute admission; there
are only few high-quality out-of-
manifestation of coronary heart disease: ST eleva- hospital
studies. Comprehensive guidelines for the
tion myocardial infarction (STEMI), non-ST eleva- diagnosis and
treatment of ACS with and without
tion myocardial infarction (NSTEMI) and unstable ST elevation
have been published by the European
angina pectoris (UAP) (Figure 5.1). The common Society of
Cardiology and the American College of
pathophysiology of ACS is a ruptured or eroded
Cardiology/American Heart Association.4,5 The cur-
atherosclerotic plaque.3 Electrocardiographic char- rent
recommendations are in line with these guide-
acteristics (absence or presence of ST elevation) lines.
differentiate STEMI from the other forms of ACS.
A NSTEMI or UAP may present with ST segment
depression or non-specific ST segment wave abnor- Diagnostic tests
in acute coronary
malities, or even a normal ECG. In the absence of syndromes
ST elevation, an increase in the plasma concentra-
tion of cardiac markers, particularly troponin T or Since early
treatment offers the greatest benefits,
I as the most specific markers of myocardial cell and myocardial
ischaemia is the leading precipitant
necrosis, indicates NSTEMI. of sudden
cardiac death, it is essential that the
0300-9572/$ — see front matter © 2005 European Resuscitation Council. All Rights
Reserved. Published by Elsevier Ireland Ltd.
doi:10.1016/j.resuscitation.2005.10.003
S88
H.-R. Arntz et al.
public are aware of the typical symptoms associ- presentations may occur in
the elderly, in females,
ated with ACS. Patients at risk, and their families, and in people with
diabetes.6,7
should be able to recognise characteristic symp-
toms such as chest pain, which may radiate into 12-lead ECG
other areas of the upper body, often accompanied
by other symptoms including dyspnoea, sweating, A 12-lead ECG is the key
investigation for assess-
nausea or vomiting and syncope. They should under- ment of an ACS. In case of
STEMI, a 12-lead ECG can
stand the importance of early activation of the indicate the need for
immediate reperfusion ther-
emergency medical service (EMS) system and, ide- apy (e.g., primary
percutaneous coronary interven-
ally, should be trained in basic life support (BLS). tion (PCI) or prehospital
thrombolysis). Recording
EMS dispatchers must be trained to recognize of a 12-lead ECG out-of-
hospital enables advanced
ACS symptoms and to ask targeted questions. When notification to the
receiving facility and expe-
an ACS is suspected, an EMS crew trained in dites treatment decisions
after hospital arrival;
advanced life support (ALS) and capable of mak- in many studies, the time
from hospital admis-
ing the diagnosis and starting treatment should sion to initiating
reperfusion therapy is reduced by
be alerted. The sensitivity, specificity and clinical 10—60 min.8—10 Recording
and transmission of diag-
impact of various diagnostic strategies have been nostic quality ECGs to the
hospital takes usually
evaluated for ACS/AMI. These include signs and less than 5 min. Trained
EMS personnel (emergency
symptoms, the 12-lead electrocardiogram (ECG) physicians, paramedics and
nurses) can identify
and biochemical markers of cardiac risk. STEMI, defined by ST
elevation of ≥0.1 mV eleva-
tion in at least two
adjacent limb leads or >0.2 mV in
Signs and symptoms of ACS/AMI two adjacent precordial
leads, with high specificity
and sensitivity comparable
to diagnostic accuracy
Even though typical symptoms such as radiating in the hospital.11—13
chest pain, shortness of breath or sweating may be
more intense and generally last longer in patients Biomarkers
with AMI, they are not adequately specific for a
reliable diagnosis of AMI. A 12-lead ECG, cardiac In the presence of a
suggestive history, the absence
biomarkers and other diagnostic tests are required of ST elevation on the ECG,
and elevated concen-
before ACS or AMI can be ruled out in the presence trations of biomarkers
(troponin T and troponin
of a typical history. Atypical symptoms or unusual I, CK, CK-MB, myoglobin)
characterise non-STEMI
European Resuscitation Council Guidelines for Resuscitation 2005
S89
65. Teo KK, Yusuf S, Pfeffer M, et al. Effects of long-term treat- 67. Swedberg
K, Held P, Kjekshus J, Rasmussen K, Ryden L,
ment with angiotensin-converting-enzyme inhibitors in the Wedel H.
Effects of the early administration of enalapril
presence or absence of aspirin: a systematic review. Lancet on
mortality in patients with acute myocardial infarction.
2002;360:1037—43. Results of
the Cooperative New Scandinavian Enalapril Sur-
66. ACE Inhibitor MI Collaborative Group. Indications for vival
Study II (CONSENSUS II). N Engl J Med 1992;327:678—
ACE inhibitors in the early treatment of acute myocar- 84.
dial infarction: systematic overview of individual data 68. Heeschen
C, Hamm CW, Laufs U, Snapinn S, Bohm M,
from 100,000 patients in randomized trials. ACE Inhibitor White HD.
Withdrawal of statins increases event rates
Myocardial Infarction Collaborative Group. Circulation in
patients with acute coronary syndromes. Circulation
1998;97:2202—12.
2002;105:1446—52.
Resuscitation (2005) 67S1, S97—S133
Introduction Guidelines
changes
0300-9572/$ — see front matter © 2005 European Resuscitation Council. All Rights
Reserved. Published by Elsevier Ireland Ltd.
doi:10.1016/j.resuscitation.2005.10.010
S98
D. Biarent et al.
tinct differences between the predominantly adult ondary cardiac arrest. The
onset of puberty, which
arrest of cardiac origin and asphyxial arrest, which is the physiological end of
childhood, is the most
is most common in children,12 so a separate paedi- logical landmark for the
upper age limit for use
atric algorithm is justified for those with a duty to of paediatric guidance.
This has the advantage of
respond to paediatric emergencies (usually health- being simple to determine,
in contrast to an age
care professionals), who are also in a position to limit in years, as age may
be unknown at the start of
receive enhanced training. resuscitation. Clearly, it
is inappropriate and unnec-
essary to establish the
onset of puberty formally; if
Compression:ventilation ratios rescuers believe the victim
to be a child they should
use the paediatric
guidelines. If a misjudgement is
The ILCOR treatment recommendation was that made and the victim turns
out to be a young adult,
the compression:ventilation ratio should be based little harm will accrue, as
studies of aetiology have
on whether one or more than one rescuers were shown that the paediatric
pattern of arrest contin-
present. ILCOR recommends that lay rescuers, ues into early adulthood.19
An infant is a child under
who usually learn only single rescuer techniques, 1 year of age; a child is
between 1 year and puberty.
should be taught to use a ratio of 30 compres- It is necessary to
differentiate between infants and
sions to 2 ventilations, which is the same as the older children, as there
are some important differ-
adult guidelines and enables anyone trained in ences between these two
groups.
BLS techniques to resuscitate children with mini-
mal additional information. Two or more rescuers Chest compression technique
with a duty to respond should learn a different
ratio (15:2), as this has been validated by animal The modification to age
definitions enables a sim-
and manikin studies.13—17 This latter group, who plification of the advice on
chest compression.
would normally be healthcare professionals, should Advice for determining the
landmarks for infant
receive enhanced training targeted specifically at compression is now the same
as for older chil-
the resuscitation of children. Although there are dren, as there is evidence
that the previous rec-
no data to support the superiority of any partic- ommendation could result in
compression over the
ular ratio in children, ratios of between 5:1 and upper abdomen.20 Infant
compression technique
15:2 have been studied in manikins, and animal remains the same: two-finger
compression for sin-
and mathematical models, and there is increasing gle rescuers and two-thumb,
encircling technique
evidence that the 5:1 ratio delivers an inadequate for two or more rescuers,21
—25 but for older children
number of compressions.14,18 There is certainly no there is no division
between the one- or two-hand
justification for having two separate ratios for chil- technique.26 The emphasis
is on achieving an ade-
dren aged greater or less than 8 years, so a single quate depth of compression
with minimal interrup-
ratio of 15:2 for multiple rescuers with a duty to tions, using one or two
hands according to rescuer
respond is a logical simplification. preference.
It would certainly negate any benefit of simplic-
ity if lay rescuers were taught a different ratio for Automated external
defibrillators
use if there were two of them, but those with a duty
to respond can use the 30:2 ratio if they are alone, Case reports published
since International Guide-
particularly if they are not achieving an adequate lines 2000 have reported
safe and successful use of
number of compressions because of difficulty in the AEDs in children less than
8 years of age.27,28 Fur-
transition between ventilation and compression. thermore, recent studies
have shown that AEDs are
capable of identifying
arrhythmias in children accu-
Age definitions rately and that, in
particular, they are extremely
unlikely to advise a shock
inappropriately.29,30 Con-
The adoption of single compression:ventilation sequently, advice on the
use of AEDs has been
ratios for children of all ages, together with the revised to include all
children aged greater than 1
change in advice on the lower age limit for the year.31 Nevertheless, if
there is any possibility that
use of automated external defibrillators (AEDs), an AED may need to be used
in children, the pur-
renders the previous guideline division between chaser should check that
the performance of the
children above and below 8 years of age unneces- particular model has been
tested against paediatric
sary. The differences between adult and paediatric arrhythmias.
resuscitation are based largely on differing aeti- Many manufacturers now
supply purpose-made
ology, as primary cardiac arrest is more common paediatric pads or
programmes, which typically
in adults whereas children usually suffer from sec- attenuate the output of the
machine to 50—75 J.32
European Resuscitation Council Guidelines for Resuscitation 2005
S99
Manual defibrillators
If you suspect that there may have been an injury • Pinch the soft part of
the nose closed with the
to the neck, try to open the airway using chin lift or index finger and thumb of
your hand on his fore-
jaw thrust alone. If this is unsuccessful, add head head.
tilt a small amount at a time until the airway is • Open his mouth a little,
but maintain the chin
open. upwards.
• Take a breath and place
your lips around the
4. Keeping the airway open, look, listen and feel mouth, making sure that
you have a good seal.
for normal breathing by putting your face close • Blow steadily into the
mouth over about 1—1.5 s,
to the child’s face and looking along the chest. watching for chest rise.
• Look for chest movements. • Maintain head tilt and
chin lift, take your mouth
• Listen at the child’s nose and mouth for breath away from the victim and
watch for his chest to
sounds. fall as air is expelled.
• Feel for air movement on your cheek. • Take another breath and
repeat this sequence
five times. Identify
effectiveness by seeing that
Look, listen and feel for no more than 10 s before the child’s chest has
risen and fallen in a similar
deciding. fashion to the movement
produced by a normal
breath.
5a If the child is breathing normally
• turn the child on his side into the recovery Rescue breaths for an
infant are performed as
position (see below) follows (Figure 6.3).
• check for continued breathing
• Ensure a neutral
position of the head and a chin
5b If the child is not breathing or is making agonal lift.
gasps (infrequent, irregular breaths) • Take a breath and cover
the mouth and nasal
• carefully remove any obvious airway obstruc- apertures of the infant
with your mouth, making
tion; sure you have a good
seal. If the nose and mouth
• give five initial rescue breaths; cannot be covered in the
older infant, the res-
• while performing the rescue breaths, note cuer may attempt to seal
only the infant’s nose
any gag or cough response to your action. or mouth with his mouth
(if the nose is used, close
These responses or their absence will form the lips to prevent air
escape).
part of your assessment of signs of a circu- • Blow steadily into the
infant’s mouth and nose
lation, which will be described later. over 1—1.5 s, sufficient
to make the chest visibly
rise.
Rescue breaths for a child over 1 year are per-
• Maintain head tilt and
chin lift, take your mouth
formed as follows (Figure 6.2).
away from the victim and
watch for his chest to
• Ensure head tilt and chin lift. fall as air is expelled.
• Take another breath and
repeat this sequence
five times.
• When more than one rescuer is available, one recovery positions; each
has its advocates. There
starts resuscitation while another rescuer goes are important principles
to be followed.
for assistance. • Place the child in as
near true lateral position
• If only one rescuer is present, undertake resus- as possible, with his
mouth dependent to enable
citation for about 1 min before going for assis- free drainage of fluid.
tance. To minimise interruption in CPR, it may • The position should be
stable. In an infant this
be possible to carry an infant or small child while may require the support
of a small pillow or
summoning help. a rolled-up blanket
placed behind the back to
• The only exception to performing 1 min of CPR maintain the position.
before going for help is in the case of a child with • Avoid any pressure on
the chest that impairs
a witnessed, sudden collapse when the rescuer is breathing.
alone. In this case cardiac arrest is likely to be • It should be possible to
turn the child onto his side
arrhythmogenic in origin and the child will need and to return him back
easily and safely, taking
defibrillation. Seek help immediately if there is into consideration the
possibility of cervical spine
no one to go for you. injury.
• Ensure the airway can be
observed and accessed
easily.
Recovery position • The adult recovery
position is suitable for use in
children.
An unconscious child whose airway is clear, and who
is breathing spontaneously, should be turned on his
side into the recovery position. There are several
Foreign-body airway
obstruction (FBAO)
No new evidence on this
subject was presented dur-
ing the 2005 Consensus
Conference. Back blows,
chest thrusts and
abdominal thrusts all increase
intrathoracic pressure and
can expel foreign bod-
ies from the airway. In
half of the episodes,
more than one technique is
needed to relieve the
obstruction.41 There are
no data to indicate which
measure should be used
first or in which order they
should be applied. If one
is unsuccessful, try the
others in rotation until
the object is cleared.
The International
Guidelines 2000 algorithm is
difficult to teach and
knowledge retention poor.
The FBAO algorithm for
children has been simpli-
fied and aligned with the
adult version (Figure 6.7).
Figure 6.5 Chest compression with one hand — child. This should improve skill
retention and encourage
© 2005 ERC. people, who might
otherwise have been reluctant,
to perform FBAO manoeuvres
on children.
Figure 6.6 Chest compression with two hands — child. Figure 6.7 Paediatric
foreign body airway obstruction
© 2005 ERC. algorithm.
European Resuscitation Council Guidelines for Resuscitation 2005
S103
The most significant difference from the adult treatment of the choking
child.
algorithm is that abdominal thrusts should not be
used to treat choking infants. Although abdominal • If the child is coughing
effectively, no external
thrusts have caused injuries in all age groups, the manoeuvre is necessary.
Encourage the child to
risk is particularly high in infants and very young cough, and monitor
continually.
children. This is because of the horizontal position • If the child’s coughing
is (or is becoming) ineffec-
of the ribs, which leaves the upper abdominal vis- tive, shout for help
immediately and determine
cera much more exposed to trauma. For this reason, the child’s conscious
level.
the guidelines for the treatment of FBAO are differ-
ent between infants and children.
2. Conscious child with
FBAO
Recognition of FBAO
• If the child is still
conscious but has absent or
When a foreign body enters the airway, the child ineffective coughing,
give back blows.
reacts immediately by coughing in an attempt to • If back blows do not
relieve the FBAO, give
expel it. A spontaneous cough is likely to be more chest thrusts to infants
or abdominal thrusts to
effective and safer than any manoeuvre a rescuer children. These
manoeuvres create an ‘artificial
might perform. However, if coughing is absent or cough’ to increase
intrathoracic pressure and dis-
ineffective and the object completely obstructs the lodge the foreign body.
airway, the child will rapidly become asphyxiated.
Active interventions to relieve FBAO are therefore Back blows. Back blows in
the infant are per-
required only when coughing becomes ineffective, formed as follows.
but they then need to be commenced rapidly and
confidently. • Support the infant in a
head downwards, prone
The majority of choking events in infants and position, to enable
gravity to assist removal of
children occur during play or eating episodes when the foreign body.
a carer is usually present; thus, the events are fre- • A seated or kneeling
rescuer should be able to
quently witnessed and interventions are usually ini- support the infant
safely across their lap.
tiated when the child is conscious. • Support the infant’s
head by placing the thumb of
Foreign-body airway obstruction is characterized one hand at the angle of
the lower jaw, and one
by the sudden onset of respiratory distress associ- or two fingers from the
same hand at the same
ated with coughing, gagging or stridor. Similar signs point on the other side
of the jaw.
and symptoms may be associated with other causes • Do not compress the soft
tissues under the
of airway obstruction, such as laryngitis or epiglot- infant’s jaw, as this
will exacerbate the airway
titis, which require different management. Suspect obstruction.
FBAO if the onset was very sudden and there are no • Deliver up to five sharp
back blows with the heel
other signs of illness and if there are clues to alert of one hand in the
middle of the back between
the rescuer, e.g. a history of eating or playing with the shoulder blades.
small items immediately before the onset of symp- • The aim is to relieve
the obstruction with each
toms. blow rather than to give
all five blows.
the child can be damaged by insertion of the tor must be experienced and
familiar with rapid-
oropharygneal airway; avoid this by inserting the sequence induction drugs.
oropharygneal airway under direct vision and pass-
ing it over a tongue depressor or laryngoscope. Tracheal tube sizes. The
tracheal tube internal
The nasopharyngeal airway is tolerated better in diameters (ID) for
different ages are
the conscious child (who has an effective gag • for neonates, 2.5—3.5 mm
according to the for-
reflex), but should not be used if there is a basal mula (gestational age in
weeks 10)
skull fracture or a coagulopathy. These simple • for infants, 4 or 4.5 mm
airway adjuncts do not protect the airway from • for children older than 1
year, according to the
aspiration of secretions, blood or stomach con- formula [(age in years/4)
+ 4]
tents.
Tracheal tube size
estimation according the
Laryngeal mask airway length of the child’s body
as measured by resusci-
tation tapes is more
accurate than using the above
The LMA is an acceptable initial airway device for formulae.67
providers experienced in its use. It may be particu-
Cuffed versus uncuffed
tracheal tubes. In the pre-
larly helpful in airway obstruction caused by upper
hospital setting, an
uncuffed tracheal tube may be
airway abnormalities. The LMA does not, however,
preferable when using sizes
of up to 5.5 mm ID (i.e.,
protect the airway from aspiration of secretions,
for children up to 8
years). In hospital, a cuffed tra-
blood or stomach contents, and therefore close
cheal tube may be useful in
certain circumstances,
observation is required. LMA use is associated with
e.g. in cases of poor lung
compliance, high air-
a higher incidence of complications in small chil-
way resistance or large
glottic air leak.68—70 The
dren compared with adults.54
correctly sized cuffed
tracheal tube is as safe as
an uncuffed tube for
infants and children (not for
Tracheal intubation neonates), provided
attention is paid to its place-
ment, size and cuff
inflation pressure; excessive
Tracheal intubation is the most secure and effective
cuff pressure can lead to
ischaemic necrosis of
way to establish and maintain the airway, prevent
the surrounding laryngeal
tissue and stenosis. Main-
gastric distension, protect the lungs against pul-
tain the cuff inflation
pressure below 20 cmH2 O and
monary aspiration, enable optimal control of the
check it regularly.71
airway pressure and provide positive end expiratory
pressure (PEEP). The oral route is preferable during Confirmation of correct
tracheal tube placement.
resuscitation. Oral intubation is usually quicker and Displaced, misplaced or
obstructed tubes occur
is associated with fewer complications than nasal frequently in the intubated
child and are asso-
placement. The judicious use of anaesthetics, seda- ciated with increased risk
of death.72,73 No sin-
tives and neuromuscular blocking drugs is indicated gle technique is 100%
reliable for distinguishing
in the conscious child to avoid multiple intubation oesophageal from tracheal
intubation.74—76 Assess-
attempts or intubation failure.55—65 The anatomy ment of the correct
tracheal tube position is made
of a child’s airway differs significantly from that of by
an adult; hence, intubation of a child requires spe-
cial training and experience. Check that tracheal • observation of the tube
passing beyond the vocal
tube placement is correct by clinical examination cords
and end-tidal capnography. The tracheal tube must • observation of
symmetrical chest wall movement
be secured, and monitoring of the vital signs is during positive pressure
ventilation
essential.66 • observation of mist in
the tube during the expi-
It is also essential to plan an alternative airway ratory phase of
ventilation
management technique in case the trachea cannot • absence of gastric
distension
be intubated. • equal air entry heard on
bilateral auscultation of
both axillae and apices
of the chest
Rapid sequence induction and intubation. The • absence of air entry into
the stomach on auscul-
child who is in cardiopulmonary arrest and deep tation
coma does not require sedation or analgesia to be • detection of end-tidal
CO2 if the child has a per-
intubated; otherwise, intubation must be preceded fusing rhythm (this may
be seen with effective
by oxygenation, rapid sedation, analgesia and the CPR)
use of neuromuscular blocking drugs to minimise • improvement or
stabilisation of SpO2 to the
intubation complications and failure.63 The intuba- expected range
European Resuscitation Council Guidelines for Resuscitation 2005
S107
Defibrillators
tion in the ratio of 15:2 (lone rescuer may use • If no vascular access is
available and a tracheal
30:2). tube is in situ, give
adrenaline, 100 mcg kg−1 , via
• Avoid rescuer fatigue by changing the rescuer this route until IV/IO
access is obtained.
performing chest compressions frequently. • Identify and treat any
reversible causes (4Hs &
• Establish cardiac monitoring. 4Ts).
C
VF/pulseless VT—–shockable
Assess cardiac rhythm and signs of circulation
(±check for a central pulse for no more than 10 s). • Attempt defibrillation
immediately (4 J kg−1 for
all shocks).
Asystole, pulseless electrical activity • Resume CPR as soon as
possible.
(PEA)—–non-shockable • After 2 min, check the
cardiac rhythm on the
monitor.
• Give adrenaline, 10 mcg kg−1 IV or IO, and repeat • Give second shock if
still in VF/pulseless
every 3—5 min. VT.
S112
D. Biarent et al.
• Immediately resume CPR for 2 min and check tion between a shockable and
a non-shockable car-
monitor; if no change, give adrenaline followed diac rhythm. Invasive
monitoring of systemic blood
immediately by a 3rd shock. pressure may help to improve
effectiveness of chest
• CPR for 2 min. compression,186 but must not
delay the provision of
• Give amiodarone if still in VF/pulseless VT fol- basic or advanced
resuscitation.
lowed immediately by a 4th shock. Shockable rhythms
comprise pulseless VT and
• Give adrenaline every 3—5 min during CPR. VF. These rhythms are more
likely in the child
• If the child remains in VF/pulseless VT, continue who presents with sudden
collapse. Non-shockable
to alternate shocks with 2 min of CPR. rhythms comprise PEA,
bradycardia (<60 beats
• If signs of life become evident, check the monitor min−1 with no signs of
circulation) and asystole. PEA
for an organised rhythm; if this is present, check and bradycardia often have
wide QRS complexes.
for a central pulse.
• Identify and treat any reversible causes (4Hs & Non-shockable rhythms
4Ts).
• If defibrillation was successful but VF/pulseless Most cardiopulmonary arrests
in children and ado-
VT recurs, resume CPR, give amiodarone and lescents are of respiratory
origin.19,44,187—189 A
defibrillate again at the dose that was effective period of immediate CPR is
therefore mandatory
previously. Start a continuous infusion of amio- in this age group, before
searching for an AED
darone. or manual defibrillator, as
their immediate avail-
ability will not improve the
outcome of a res-
Reversible causes of cardiac arrest (4 Hs piratory arrest.11,13
Bystander CPR is associated
and 4 Ts) with a better neurological
outcome in adults and
children.9,10,190 The most
common ECG patterns in
infants, children and
adolescents with cardiopul-
• Hypoxia monary arrest are asystole
and PEA. PEA is charac-
• Hypovolaemia terised by organised, wide
complex electrical activ-
• Hyper/hypokalaemia ity, usually at a slow rate,
and absent pulses. PEA
• Hypothermia commonly follows a period of
hypoxia or myocardial
• Tension pneumothorax ischaemia, but occasionally
can have a reversible
• Tamponade (coronary or pulmonary) cause (i.e., one of the 4
H’s and 4 T’S) that led to
• Toxic/therapeutic disturbances a sudden impairment of
cardiac output.
• Thrombosis (coronary or pulmonary)
Shockable rhythms
Sequence of events in cardiopulmonary
arrest VF occurs in 3.8—19% of
cardiopulmonary arrests
in children9,45,188,189 ;
the incidence of VF/pulseless
• When a child becomes unresponsive, with- VT increases with
age.185,191 The primary deter-
out signs of life (no breathing, cough or any minant of survival from
VF/pulseless VT cardiopul-
detectable movement), start CPR immediately. monary arrest is the time to
defibrillation. Prehospi-
• Provide BMV with 100% oxygen. tal defibrillation within the
first 3 min of witnessed
• Commence monitoring. Send for a manual or adult VF arrest results in
>50% survival. However,
automatic external defibrillator (AED) to identify the success of defibrillation
decreases dramatically
and treat shockable rhythms as quickly as possi- as the time to defibrillation
increases; for every
ble. minute delay in
defibrillation (without any CPR),
survival decreases by 7—10%.
Survival after more
In the less common circumstance of a witnessed than 12 min of VF in adult
victims is <5%.192 Car-
sudden collapse, early activation of emergency ser- diopulmonary resuscitation
provided before defib-
vices and getting an AED may be more appropriate; rillation for response
intervals longer than 5 min
start CPR as soon as possible. improved outcome in some
studies,193,194 but not
Rescuers must perform CPR with minimal inter- in others.195
ruption until attempted defibrillation.
Drugs in shockable rhythms
Cardiac monitoring
Adrenaline is given every 3—
5 min by the IV or IO
Position the cardiac monitor leads or defibrillation route in preference to the
tracheal tube route.
paddles as soon as possible, to enable differentia- Amiodarone is indicated in
defibrillation-resistant
European Resuscitation Council Guidelines for Resuscitation 2005
S113
the parents do not interfere with or distract the (0.2%) appeared to need
resuscitation at delivery.
resuscitation. If the presence of the parents is Of these, 90% responded
to mask inflation alone,
impeding the progress of the resuscitation, they whereas the remaining 10%
appeared not to respond
should be sensitively asked to leave. When appro- to mask inflation and
therefore were intubated at
priate, physical contact with the child should be birth.
allowed and, wherever possible, the parents should Resuscitation or
specialist help at birth is more
be allowed to be with their dying child at the final likely to be needed by
babies with intrapartum evi-
moment.256,261—264 dence of significant fetal
compromise, babies deliv-
The leader of the resuscitation team, not the ering before 35 weeks’
gestation, babies delivering
parents, will decide when to stop the resuscita- vaginally by the breech
and multiple pregnancies.
tion; this should be expressed with sensitivity and Although it is often
possible to predict the need
understanding. After the event the team should be for resuscitation before
a baby is born, this is not
debriefed, to enable any concerns to be expressed always the case.
Therefore, personnel trained in
and for the team to reflect on their clinical practice newborn life support
should be easily available at
in a supportive environment. every delivery and,
should there be any need for
resuscitation, the care
of the baby should be their
sole responsibility. One
person experienced in tra-
cheal intubation of the
newborn should also be
6c Resuscitation of babies at birth
easily available for
normal low-risk deliveries and,
ideally, in attendance
for deliveries associated with
Introduction a high risk for neonatal
resuscitation. Local guide-
lines indicating who
should attend deliveries should
The following guidelines for resuscitation at birth be developed based on
current practice and clinical
have been developed during the process that cul- audit.
minated in the 2005 International Consensus Con- An organised programme
educating in the stan-
ference on Emergency Cardiovascular Care (ECC) dards and skills required
for resuscitation of the
and Cardiopulmonary Resuscitation (CPR) Science newborn is therefore
essential for any institution
with Treatment Recommendations.265 They are an in which deliveries
occur.
extension of the guidelines already published by
the ERC,2 and take into account recommenda-
tions made by other national266 and international Planned home deliveries
organisations.267
The recommendations for
those who should attend
The guidelines that follow do not define the only
a planned home delivery
vary from country to coun-
way that resuscitation at birth should be achieved;
try, but the decision to
undergo a planned home
they merely represent a widely accepted view of
delivery, once agreed by
the medical and midwifery
how resuscitation at birth can be carried out both
staff, should not
compromise the standard of ini-
safely and effectively.
tial resuscitation at
birth. There will inevitably
be some limitations to
resuscitation of a newborn
baby in the home because
of the distance from
Preparation further assistance, and
this must be made clear
to the mother at the time
plans for home delivery
Relatively few babies need any resuscitation at are made. Ideally, two
trained professionals should
birth. Of those that do need help, the overwhelm- be present at all home
deliveries;269 one of these
ing majority will require only assisted lung aera- must be fully trained and
experienced in providing
tion. A small minority may need a brief period of mask ventilation and
chest compressions in the
chest compressions in addition to lung aeration. newborn.
Of 100,000 babies born in Sweden in 1 year, only
10 per 1000 (1%) babies weighing 2.5 kg or more Equipment and environment
appeared to need resuscitation at delivery.268 Of
those babies receiving resuscitation, 8 per 1000 Resuscitation at birth is
often a predictable event.
responded to mask inflation and only 2 per 1000 It is therefore simpler
to prepare the environment
appeared to need intubation.268 The same study and the equipment before
delivery of the baby
tried to assess the unexpected need for resuscita- than is the case in adult
resuscitation. Resuscita-
tion at birth, and found that for low-risk babies, i.e. tion should ideally take
place in a warm, well-lit,
those born after 32 weeks’ gestation and follow- draught-free area with a
flat resuscitation surface
ing an apparently normal labour, about 2 per 1000 placed below a radiant
heater and other resusci-
S116
D. Biarent et al.
The Apgar scoring system was not designed to iden- Group 1: vigorous
breathing or crying
tify prospectively babies needing resuscitation.273 good tone
Several studies have also suggested that it is rapidly
becoming pink
heart rate
higher than 100 beats min−1
highly subjective.274 However, components of the
score, namely respiratory rate, heart rate and This baby requires no
intervention other than
colour, if assessed rapidly, can identify babies need- drying, wrapping in a warm
towel and, where
ing resuscitation.275 Furthermore, repeated assess- appropriate, handing to
the mother. The baby will
ment of these components can indicate whether the remain warm through skin-
to-skin contact with
baby is responding or whether further efforts are mother under a cover, and
may be put to the breast
needed. at this stage.
European Resuscitation Council Guidelines for Resuscitation 2005
S117
two thumbs side by side over the lower third of depth of approximately one
third of the anterior-
the sternum, with the fingers encircling the torso posterior diameter of the
chest. A compression to
and supporting the back (Figure 6.13).21,22,25,278,279 relaxation ratio with a
slightly shorter compres-
The lower third of the sternum is compressed to a sion than relaxation phase
offers theoretical advan-
tages for blood flow in the
very young infant.280
Do not lift the thumbs off
the sternum during
the relaxation phase, but
allow the chest wall to
return to its relaxed
position between compres-
sions. Use a 3:1 ratio of
compressions to ventila-
tions, aiming to achieve
approximately 120 events
min−1 , i.e. approximately
90 compressions and 30
breaths. However, the
quality of the compressions
and breaths are more
important than the rate.281
Check the heart rate
after about 30 s and peri-
odically thereafter.
Discontinue chest compressions
Figure 6.11 Newborn head in neutral position. © 2005 when the spontaneous heart
rate is faster then 60
Resuscitation Council (UK). beats min−1 .
European Resuscitation Council Guidelines for Resuscitation 2005
S119
It is vitally important that the team caring for Five years ago, a large
randomised controlled study
the newborn baby informs the parents of the showed that attempting to
intubate and aspirate
baby’s progress. At delivery adhere to the routine inhaled meconium from the
tracheas of vigorous
local plan and, if possible, hand the baby to the infants at birth was not
beneficial.290 A more recent
mother at the earliest opportunity. If resuscitation large multicentre randomised
controlled study has
is required, inform the parents of the procedures now shown that suctioning
meconium from the
being undertaken and why they are required. baby’s nose and mouth before
delivery of the baby’s
Decisions to discontinue resuscitation ideally chest (intrapartum
suctioning) does not reduce
should involve senior paediatric staff. Whenever the incidence or severity of
meconium aspiration
possible, the decision to attempt resuscitation of syndrome.291 Intrapartum
suctioning is therefore
an extremely preterm baby should be taken in close no longer recommended.
Intubation and suction of
consultation with the parents and senior paediatric meconium from the trachea of
non-vigorous infants
and obstetric staff. Where a difficulty has been born through meconium-
stained liquor is still rec-
foreseen, for example in the case of severe con- ommended.
genital malformation, the options and prognosis
should be discussed with the parents, midwives, Air or 100% oxygen
obstetricians and birth attendants before deliv-
ery. Several studies in recent
years have raised concerns
All discussions and decisions should be carefully about the potential adverse
effects of 100% oxygen
recorded in the mother’s notes before delivery and on respiratory physiology
and cerebral circulation,
also in the baby’s records after birth. and the potential tissue
damage from oxygen free
radicals. There are also
concerns about tissue dam-
age from oxygen deprivation
during and following
asphyxia. Studies examining
blood pressure, cere-
Specific questions addressed at the bral perfusion, and various
biochemical measures
2005 Consensus Conference of cell damage in
asphyxiated animals resuscitated
with 100% versus 21% oxygen,
have shown conflict-
Maintaining normal temperature in preterm ing results.292—296 One
study of preterm infants
infants (below 33 weeks’ gestation)
exposed to 80% oxy-
gen found lower cerebral
blood flow when com-
Significantly, preterm babies are likely to become pared with those stabilised
with 21% oxygen.297
hypothermic despite careful application of the tra- Some animal data indicate
the opposite effect,
ditional techniques for keeping them warm (dry- i.e. reduced blood pressure
and cerebral perfu-
ing, wrapping and placing under radiant heat).282 sion with air versus 100%
oxygen.292 Meta-analysis
Several randomised controlled trials and observa- of four human studies
demonstrated a reduction
tional studies have shown that placing preterm in mortality and no evidence
of harm in infants
babies under radiant heat and then covering the resuscitated with air versus
those resuscitated with
babies with food-grade plastic wrapping, without 100% oxygen. However, there
are several signifi-
drying them, significantly improves temperature on cant concerns about the
methodology of these stud-
admission to intensive care compared with tra- ies, and these results
should be interpreted with
ditional techniques.283—285 The baby’s tempera- caution.80,298
ture must be monitored closely because of the At present, the standard
approach to resuscita-
small but described risk of hyperthermia with this tion is to use 100% oxygen.
Some clinicians may
technique.286 All resuscitation procedures, includ- elect to start resuscitation
with an oxygen con-
ing intubation, chest compression and insertion of centration less than 100%,
including some who
lines, can be achieved with the plastic cover in may start with air. Evidence
suggests that this
place. approach may be reasonable.
However, where pos-
Infants born to febrile mothers have been sible, ensure supplemental
oxygen is available
reported to have a higher incidence of perina- for use if there is no rapid
improvement follow-
tal respiratory depression, neonatal seizures, early ing successful lung
aeration. If supplemental oxy-
mortality and cerebral palsy.286—288 Animal stud- gen is not readily
available, ventilate the lungs
ies indicate that hyperthermia during or following with air. Supplemental
oxygen is recommended
ischaemia is associated with a progression of cere- for babies who are breathing
but have central
bral injury.233,289 Hyperthermia should be avoided. cyanosis.
European Resuscitation Council Guidelines for Resuscitation 2005
S121
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doi:10.1016/j.resuscitation.2005.10.004
S136
J. Soar et al.
potassium shifts from the cellular to the vascular • first-degree heart block
(prolonged PR interval)
space. When serum pH increases, serum potassium >0.2 s;
decreases because potassium shifts intracellularly. • flattened or absent P waves;
We therefore anticipate the effects of pH changes • tall, peaked (tented) T
waves, larger than R wave
on serum potassium during the therapy for hyper- in more than one lead;
kalaemia or hypokalaemia. • ST segment depression;
• S and T waves merging;
Hyperkalaemia • widened QRS >0.12 s;
• ventricular tachycardia
(VT);
This is the most common electrolyte disorder asso- • bradycardia;
ciated with cardiopulmonary arrest. It is usually • cardiac arrest, i.e.,
pulseless electrical activity
caused by increased potassium release from the (PEA), ventricular
fibrillation (VF), asystole.
cells or impaired excretion by the kidneys.
Treatment of hyperkalaemia.
The five key steps
Definition. There is no universal definition, in treating hyperkalaemia
are:
although we have defined hyperkalaemia as a serum
potassium concentration higher than 5.5 mmol l−1 ; 1. cardiac protection by
antagonising the effects of
in practice, hyperkalaemia is a continuum. As hyperkalaemia;
the potassium concentration increases above this 2. shifting potassium into
cells;
value, the risk of adverse events increases and the 3. removing potassium from
the body;
need for urgent treatment increases. Severe hyper- 4. monitoring serum potassium
for rebound hyper-
kalaemia has been defined as a serum potassium kalaemia;
concentration higher than 6.5 mmol l−1 . 5. prevention of recurrence
of hyperkalaemia.
When hyperkalaemia is
strongly suspected, e.g.,
Causes. There are several potential causes of in the presence of ECG
changes, start life-saving
hyperkalaemia, including renal failure, drugs treatment even before
laboratory results are avail-
(angiotensin converting enzyme inhibitors (ACEI), able. The management of
hyperkalaemia is the sub-
angiotensin II receptor blockers (ARB), potassium- ject of a recent Cochrane
review.4
sparing diuretics, non-steroidal anti-inflammatory
drugs (NSAIDs), beta-blockers, trimethoprim, tis- Patient not in cardiac
arrest. If the patient
sue breakdown (rhabdomyolysis, tumour lysis, is not in cardiac arrest,
assess fluid status;
haemolysis), metabolic acidosis, endocrine disor- if hypovolaemic, give fluid to
enhance urinary
ders (Addison’s disease), hyperkalaemic periodic potassium excretion. The
values for classification
paralysis, or diet, which may be the sole cause are an approximate guide. For
mild elevation
in patients with established renal failure. Abnor- (5.5—6 mmol l−1 ), remove
potassium from the body
mal erythrocytes or thrombocytosis may cause a with:
spuriously high potassium concentration. The risk
• potassium exchange resins,
i.e., calcium reso-
of hyperkalaemia is even greater when there is
nium 15—30 g or sodium
polystyrene sulfonate
a combination of factors, such as the concomi-
(Kayexalate® ) 15—30 g in
50—100 ml of 20% sor-
tant use of ACEI and NSAIDs or potassium-sparing
bitol, given either orally
or by retention enema
diuretics.
(onset in 1—3 h, maximal
effect at 6 h);
Recognition of hyperkalaemia. Exclude hyper- • diuretics, i.e., furosemide
1 mg kg−1 IV slowly
kalaemia in patients with an arrhythmia or car- (onset with the diuresis);
diac arrest.2 Patients may present with weakness • dialysis; haemodialysis is
more efficient than
progressing to flaccid paralysis, paraesthesia or peritoneal dialysis at
removing potassium (imme-
depressed deep tendon reflexes. The first indica- diate onset, 25—30 mmol
potassium h−1 removed
tor of hyperkalaemia may also be the presence of with haemodialysis).
ECG abnormalities, arrhythmias, cardiopulmonary For moderate elevation (6—
6.5 mmol l−1 ) with-
arrest or sudden death. The effect of hyper- out ECG changes, shift
potassium into cells with:
kalaemia on the ECG depends on the absolute serum
potassium as well as the rate of increase. Most • dextrose/insulin: 10 units
short-acting insulin
patients will have ECG abnormalities at a serum and 50 g glucose IV over 15
—30 min (onset in
potassium concentration higher than 6.7 mmol l−1 .3 15—30 min, maximal effect
at 30—60 min; mon-
The ECG manifestations of hyperkalaemia are usu- itor blood glucose). Use in
addition to removal
ally progressive and include: strategies above.
European Resuscitation Council Guidelines for Resuscitation 2005
S137
For severe elevation (≥6.5 mmol l−1 ) without breakdown. Dialysis is also
indicated when hyper-
ECG changes, shift potassium into cells with: kalaemia is resistant to
medical management.
Serum potassium frequently
rebounds after ini-
• salbutamol, 5 mg nebulised. Several doses may tial treatment. In unstable
patients, continuous
be required (onset in 15—30 min); veno-venous haemofiltration
(CVVH) is less likely
• sodium bicarbonate, 50 mmol IV over 5 min if to compromise cardiac
output than intermittent
metabolic acidosis present (onset in 15—30 min). haemodialysis.
Bicarbonate alone is less effective than glucose
plus insulin or nebulised salbutamol; it is best Hypokalaemia
used in conjunction with these medications;5,6
• use multiple shifting agents in addition to Hypokalaemia is common in
hospital patients.7
removal strategies above. Hypokalaemia increases the
incidence of arrhyth-
mias, particularly in
patients with pre-existing
For severe elevation (≥6.5 mmol l−1 ) with toxic heart disease and in those
treated with digoxin.
ECG changes, protect the heart first with:
Definition. Hypokalaemia is
defined as a serum
• calcium chloride, i.e., 10 ml 10% calcium chloride
potassium <3.5 mmol l−1 .
Severe hypokalaemia is
IV over 2—5 min to antagonise the toxic effects of
defined as a K+ < 2.5 mmol
l−1 and may be associ-
hyperkalaemia at the myocardial cell membrane.
ated with symptoms.
This protects the heart by reducing the risk of
VF, but does not lower serum potassium (onset in Causes. Causes of
hypokalaemia include gas-
1—3 min). Use in addition to potassium removal trointestinal loss
(diarrhoea), drugs (diuretics,
and shifting strategies stated above. laxatives, steroids), renal
losses (renal tubular
disorders, diabetes
insipidus, dialysis), endocrine
Patient in cardiac arrest. If the patient is in
disorders (Cushing’s
syndrome, hyperaldostero-
cardiac arrest, there are no modifications to BLS
nism), metabolic alkalosis,
magnesium depletion
in the presence of electrolyte abnormalities. For
and poor dietary intake.
Treatment strategies used
ALS, follow the universal algorithm. The general
for hyperkalaemia may also
induce hypokalaemia.
approach to treatment depends on the degree of
hyperkalaemia, rate of rise of serum potassium and Recognition of
hypokalaemia. Exclude hypoka-
the patient’s clinical condition. laemia in every patient
with an arrhythmia or
In cardiopulmonary arrest, protect the heart cardiac arrest. In dialysis
patients, hypokalaemia
first, then apply shifting and removal strategies occurs commonly at the end
of a haemodialysis
using: session or during treatment
with continuous ambu-
latory peritoneal dialysis
(CAPD).
• calcium chloride: 10 ml of 10% calcium chloride
As serum potassium
concentration decreases,
IV by rapid bolus injection to antagonise the toxic
the nerves and muscles are
predominantly
effects of hyperkalaemia at the myocardial cell
affected, causing fatigue,
weakness, leg
membrane;
cramps and constipation. In
severe cases
• sodium bicarbonate: 50 mmol IV by rapid injec-
(K+ < 2.5 mmol l−1 ),
rhabdomyolysis, ascending
tion (if severe acidosis or renal failure);
paralysis and respiratory
difficulties may occur.
• dextrose/insulin: 10 units short-acting insulin and
ECG features of
hypokalaemia comprise:
50 g glucose IV by rapid injection;
• haemodialysis: consider this for cardiac arrest • U waves;
induced by hyperkalaemia, which is resistant to • T-wave flattening;
medical treatment. • ST segment changes;
• arrhythmias, especially
if patient is taking
Indications for dialysis. Haemodialysis is the digoxin;
most effective method of removal of potassium • cardiopulmonary arrest
(PEA, VF, asystole).
from the body. The principal mechanism of action
is the diffusion of potassium ions across the Treatment. Treatment
depends on the severity of
transmembrane potassium ion gradient. The typ- hypokalaemia and the
presence of symptoms and
ical decline in serum potassium is 1 mmol l−1 in ECG abnormalities. Gradual
replacement of potas-
the first 60 min, followed by 1 mmol l−1 over the sium is preferable but in
emergency intravenous
next 2 h. Consider haemodialysis early for hyper- potassium is required. The
maximum recommended
kalaemia associated with established renal fail- IV dose of potassium is 20
mmol h−1 , but more rapid
ure, oliguric acute renal failure (<400 ml day−1 infusion, e.g., 2 mmol
min−1 for 10 min followed by
urine output) or when there is marked tissue 10 mmol over 5—10 min is
indicated for unstable
S138
J. Soar et al.
Haemodialysis
Hypocalcaemia (Ca2+ Chronic renal failure Paraesthesia
Prolonged QT interval Calcium chloride 10%, 10—40 ml
<2.1 mmol l−1 Acute pancreatitis Tetany
T-wave inversion Magnesium sulphate 50%, 4—8 mmol (if
Calcium channel blocker Seizures
Heart block necessary)
overdose AV-block
Cardiac arrest
Toxic shock syndrome Cardiac arrest
Rhabdomyolysis
Tumour lysis syndrome
Hypermagnesaemia Renal failure Confusion
Prolonged PR and QT Calcium chloride 10%, 5—10 ml,
(Mg2+ > 1.1 mmol l−1 ) Iatrogenic Weakness
intervals repeated if necessary
Respiratory depression
T-wave peaking Ventilatory support if necessary
AV-block
AV-block Saline diuresis: 0.9% saline with
Cardiac arrest
Cardiac arrest furosemide 1 mg kg−1 IV
Haemodialysis
S139
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J. Soar et al.
Circulation and
defibrillation
Defibrillation
Follow standard
advanced life support protocols. If
If the victim is unresponsive and not breathing and severe hypothermia is
present (core body temper-
an AED is available, attach it to the victim and ature ≤30 ◦ C or 86 ◦
F), limit defibrillation attempts
turn it on. Before attaching the AED pads, dry to three, and withhold
IV drugs until the core
the victim’s chest to enable adherence. Deliver body temperature
increases above these levels. If
shocks according to the AED prompts. If the vic- moderate hypothermia is
present, give IV drugs at
tim is hypothermic with a core body temperature longer than standard
intervals (see section 7d).
≤30 ◦ C (86 ◦ F), limit defibrillation to a total of three During prolonged
immersion, victims may
attempts until the core body temperature rises become hypovolaemic
from the hydrostatic pres-
above 30 ◦ C (86 ◦ F).74 sure of water on the
body. Give IV fluid to correct
the hypovolaemia but
avoid excessive volumes,
Regurgitation during resuscitation which may cause
pulmonary oedema. After return
of spontaneous
circulation, use haemodynamic
Regurgitation of stomach contents is common fol- monitoring to guide
fluid resuscitation.
lowing resuscitation from drowning and will com-
plicate efforts to maintain a patent airway. In one Discontinuing
resuscitation efforts
study, regurgitation occurred in two-thirds of vic-
tims who received rescue breathing and 86% of vic- Making a decision to
discontinue resuscitation
tims who required compression and ventilation.75 efforts on a victim of
drowning is notoriously dif-
If regurgitation occurs, turn the victim’s mouth to ficult. No single factor
can accurately predict good
the side and remove the regurgitated material using or poor survival with
100% certainty. Decisions made
directed suction if possible. If spinal cord injury is in the field frequently
prove later to have been
suspected, log-roll the victim, keeping the head, incorrect.78 Continue
resuscitation unless there
neck and torso aligned, before aspirating the regur- is clear evidence that
resuscitation attempts are
gitated material. Log-rolling will require several futile (e.g., massive
traumatic injuries, rigor mor-
rescuers. tis, putrefaction
etc.), or timely evacuation to
S144
J. Soar et al.
heat loss and rapid transfer to the hospital. Remove tions, or secondary to
endogenous heat produc-
cold or wet clothing as soon as possible. Cover the tion.
dry casualties with blankets and keep them out of Environment-related
hyperthermia occurs where
the wind. heat, usually in the form
of radiant energy, is
Rewarming may be passive external, active absorbed by the body at a
rate faster than that can
external, or active internal. Passive warming is be lost by thermoregulatory
mechanisms. Hyper-
achieved with blankets and a warm room, and is thermia occurs along a
continuum of heat-related
suitable for conscious victims with mild hypother- conditions, starting with
heat stress, progressing
mia. In severe hypothermia or cardiac arrest, to heat exhaustion, to heat
stroke (HS) and finally
active warming is required, but this must not multiorgan dysfunction and
cardiac arrest in some
delay transport to a hospital where more advanced instances.108
rewarming techniques are available. Several tech- Malignant hyperthermia
(MH) is a rare disorder of
niques have been described, although there are no skeletal muscle calcium
homeostasis characterised
clinical trials of outcome to determine the best by muscle contracture and
life-threatening hyper-
rewarming method. Studies show that forced air metabolic crisis following
exposure of genetically
rewarming and warm IV fluids are effective in predisposed individuals to
halogenated anaesthet-
patients with severe hypothermia and a perfus- ics and depolarising muscle
relaxants.109,110
ing rhythm.99,100 Other warming techniques include The key features and
treatment of heat stress
the use of warm humidified gases, gastric, peri- and heat exhaustion are
included in Table 7.2.
toneal, pleural or bladder lavage with warm fluids
(at 40 ◦ C), and extracorporeal blood warming with Heat stroke (HS)
partial bypass.87,90,101—103
In the patient with cardiac arrest and hypother- HS is a systemic
inflammatory response with a
mia, cardiopulmonary bypass is the preferred core temperature above 40.6
◦ C, accompanied by
method of active internal rewarming because it mental state change and
varying levels of organ
also provides circulation, oxygenation and ventila- dysfunction. There are two
forms of HS: clas-
tion, while the core body temperature is increased sic non-exertion heat
stroke (CHS) occuring dur-
gradually.104,105 Survivors in one case series had an ing high environmental
temperatures and often
average of 65 min of conventional CPR before car- effecting the elderly
during heat waves;111 exer-
diopulmonary bypass.105 Unfortunately, facilities tion heat stroke (EHS)
occuring during strenu-
for cardiopulmonary bypass are not always avail- ous physical exercise in
high environmental tem-
able and a combination of methods may have to be peratures and/or high
humidity usually effecting
used. healthy young adults.112
Mortality from HS ranges
During rewarming, patients will require large between 10 and 50%.113
volumes of fluids as their vascular space expands
with vasodilation. Warm all the IV fluids. Use con- Predisposing factors
tinuous haemodynamic monitoring and, if possi-
ble, treat the patient in a critical care unit. Avoid The elderly are at an
increased risk for heat-related
hyperthermia during and after the warming period. illness because of
underlying illness, medication
Although there are no formal studies, once ROSC use, declining
thermoregulatory mechanisms and
has been achieved use standard strategies for post- limited social support.
There are several risk fac-
resuscitation care, including mild hypothermia if tors: lack of
acclimatisation, dehydration, obe-
appropriate (section 4g). There is no evidence sity, alcohol,
cardiovascular disease, skin condi-
for the routine use of steroids, barbiturates or tions (psoriasis, eczema,
scleroderma, burn, cys-
antibiotics.106,107 tic fibrosis),
hyperthyroidism, phaeochromocytoma
and drugs
(anticholinergics, diamorphine, cocaine,
amphetamine,
phenothiazines, sympathomimetics,
7e. Hyperthermia calcium channel blockers,
beta-blockers).
Hyperthermia occurs when the body’s ability Heat stroke can resemble
septic shock and may be
to thermoregulate fails, and core temperature caused by similar
mechanisms.114 Features include:
exceeds the one that is normally maintained • core temperature 40.6 ◦ C
or more;
by homeostatic mechanisms. Hyperthermia may • hot, dry skin (sweating
is present in about 50% of
be exogenous, caused by environmental condi- cases of exertional heat
stroke);
European Resuscitation Council Guidelines for Resuscitation 2005
S147
Salt replacement
Heat exhaustion Systemic reaction to prolonged heat exposure
As above
(hours to days)
Temperature >37 ◦ C and <40 ◦ C
Consider IV fluids and ice packs
Envenomation
Observation
Rarely, insect envenomation by bees, but not
wasps, leaves a venom sac. Immediately scrape Warn patients with even
moderate attacks of the
away any insect parts at the site of the sting.182 possibility of an early
recurrence of symptoms and,
Squeezing may increase envenomation. in some circumstances, keep
them under observa-
tion for 8—24 h. This
caution is particularly applica-
Cardiac arrest ble to:
In addition to the ALS drugs, consider the following • severe reactions with slow
onset due to idio-
therapies. pathic anaphylaxis;
• reactions in severe
asthmatics or with a severe
Rapid fluid resuscitation asthmatic component;
• reactions with the
possibility of continuing
Near-fatal anaphylaxis produces profound vasodila- absorption of allergen;
tion and a relative hypovolaemia. Massive volume • patients with a previous
history of biphasic
replacement is essential. Use at least two large- reactions.179,183—187
bore cannulae with pressure bags to give large vol-
umes (as much as 4—8 l IV fluid may be necessary in A patient who remains
symptom-free for 4 h after
the immediate resuscitation period). treatment may be
discharged.188
European Resuscitation Council Guidelines for Resuscitation 2005
S155
traumatic event (e.g., fall, road traffic accident, but treatment on scene
should focus on good qual-
etc.). Traumatic injuries may not be the primary ity BLS and ALS and
exclusion of reversible causes.
cause of a cardiorespiratory arrest. Look for and treat any
medical condition that may
have precipitated the
trauma event. Undertake
only the essential
lifesaving interventions on scene
Mechanism of injury
and, if the patient has
signs of life, transfer rapidly
Blunt trauma to the nearest appropriate
hospital. Consider on-
scene thoracostomy for
appropriate patients.227,228
Of 1242 patients with cardiac arrest after blunt Do not delay for unproven
interventions, such as
trauma, 19 (1.5%) survived, but only 2 (0.16%) had spinal immobilisation.229
a good neurological outcome (Table 7.4).
Resuscitative thoracotomy
Penetrating trauma
Prehospital. Resuscitative
thoracotomy has been
Of 839 patients with cardiac arrest after pene- reported as futile if out-
of-hospital time has
trating injury, there were 16 (1.9%) survivors, of exceeded 30 min;225 others
consider thoracotomy
whom 12 (1.4%) had a good neurological outcome to be futile in patients
with blunt trauma requiring
(Table 7.4). more than 5 min of
prehospital CPR and in patients
with penetrating trauma
requiring more than 15 min
Signs of life and initial ECG activity of CPR.226 With these time
limits in mind, one UK
service recommends that,
if surgical intervention
There are no reliable predictors of survival for cannot be accomplished
within 10 min after loss
TCRA. One study reported that the presence of of pulse in patients with
penetrating chest injury,
reactive pupils and sinus rhythm correlated signif- on-scene thoracotomy
should be considered.227
icantly with survival.217 In a study of penetrating Following this approach,
of 39 patients who
trauma, pupil reactivity, respiratory activity and underwent thoracotomy at
scene, 4 patients sur-
sinus rhythm were correlated with survival but were vived and 3 of these made
a good neurological
unreliable.207 Three studies reported no survivors recovery.
among patients presenting with asystole or agonal
rhythms.202,207,218 Another reported no survivors in Hospital. A relatively
simple technique for
PEA after blunt trauma.219 Based on these studies, resuscitative thoracotomy
has been described
the American College of Surgeons and the National recently.228,230 The
American College of Surgeons
Association of EMS Physicians produced prehospi- has published practice
guidelines for emergency
tal guidelines on withholding resuscitation.220 They department thoracotomy
(EDT) based on a meta-
recommend withholding resuscitation in: analysis of 42 outcome
studies including 7035
EDTs.231 The overall
survival rate was 7.8%, and
• blunt trauma victims presenting apnoeic and of 226 survivors (5%),
only 34 (15%) exhibited a
pulseless, and without organised ECG activity; neurological deficit. The
investigators concluded
• penetrating trauma victims found apnoeic and the following:
pulseless after rapid assessment for signs of life,
such as pupillary reflexes, spontaneous move- • After blunt trauma, EDT
should be limited to
ment or organised ECG activity. those with vital signs
on arrival and a witnessed
cardiac arrest
(estimated survival rate 1.6%).
A recent retrospective study questions these • Emergency department
thoracotomy is best
recommendations: in a series of 184 TCRA vic- applied to patients with
penetrating cardiac
tims, several survivors met the criteria for non- injuries, who arrive at
the trauma centre after
resuscitation.221 short on-scene and
transport times, with wit-
nessed signs of life or
ECG activity (estimated
Treatment survival rate 31%).
• Emergency department
thoracotomy should be
Survival from TCRA is correlated with duration of undertaken in
penetrating non-cardiac thoracic
CPR and prehospital time.205,222—226 Prolonged CPR injuries even though
survival rates are low.
is associated with a poor outcome; the maximum • Emergency department
thoracotomy should be
CPR time associated with a favourable outcome is undertaken in patients
with exsanguinating
16 min.205,222—224 The level of prehospital interven- abdominal vascular
injury even though survival
tion will depend on the skills of local EMS providers, rates are low. This
procedure should be used as
S158
J. Soar et al.
Chest decompression
Ultrasound
Effective decompression of a tension pneumothorax
can be achieved quickly by lateral thoracostomy, Ultrasound is a valuable
tool in the evaluation of the
which is likely to be more effective than needle compromised trauma victim.
Haemoperitoneum,
thoracostomy and quicker than inserting a chest haemo- or pneumothorax and
cardiac tamponade
tube.237 can be diagnosed reliably in
minutes even in the
prehospital phase.246
Diagnostic peritoneal lavage
Effectiveness of chest compressions in TCRA and needle
pericardiocentesis have virtually disap-
peared from clinical
practice since the introduction
In hypovolaemic cardiac arrest or cardiac tam- of sonography in trauma
care. Prehospital ultra-
ponade, chest compressions are unlikely to be as sound is now available,
although its benefits are yet
effective as in cardiac arrest from other causes;238 to be proven.
nonetheless, return of spontaneous circulation with
ALS in patients with TCRA is well described. Chest
compressions are still the standard of care in Vasopressors
patients with cardiac arrest, irrespective of aeti-
The possible role of
vasopressors (e.g., vasopressin)
ology.
in trauma resuscitation is
unclear and is based
mainly on case reports.247
Haemorrhage control
Early haemorrhage control is vital. Handle the
patient gently at all times, to prevent clot disrup-
tion. Apply external compression and pelvic and
7j. Cardiac arrest
associated with
limb splints when appropriate. Delays in surgical pregnancy
haemostasis are disastrous for patients with exsan-
guinating trauma. Overview
ABCDE approach. The key step is to stop the bleed- Amniotic fluid embolism
ing. Consider the following:
Amniotic fluid embolism may
present with breath-
• fluid resuscitation including use of rapid transfu- lessness, cyanosis,
arrhythmias, hypotension and
sion system and cell salvage;256 haemorrhage associated with
disseminated intra-
• correction of coagulopathy. There may be a role vascular coagulopathy.272
Presentation is variable
for recombinant Factor VIIa;257 and may be similar to
anaphylaxis. Treatment is
• oxytocin and prostaglandins to correct uterine supportive, as there is no
specific therapy. Suc-
atony;258 cessful use of
cardiopulmonary bypass for women
• uterine compression sutures;259 suffering life-threatening
amniotic fluid embolism
• radiological embolisation;260 during labour and delivery
is reported.273
• hysterectomy;
• aortic cross-clamping in catastrophic haemo-
rrhage.261 If immediate resuscitation
attempts fail
Drugs
Consider the need for an
emergency hysterotomy
Iatrogenic overdose is possible in eclamptic women or Caesarean section as soon
as a pregnant woman
receiving magnesium sulphate, particularly if the goes into cardiac arrest. In
some circumstances
woman becomes oliguric. Give calcium to treat immediate resuscitation
attempts will restore a
magnesium toxicity (see life-threatening elec- perfusing rhythm; in early
pregnancy this may
trolyte abnormalities). enable the pregnancy to
proceed to term. When
Central neural blockade for analgesia or anaes- initial resuscitation
attempts fail, delivery of
thesia may cause problems due to sympathetic the fetus may improve the
chances of successful
blockade (hypotension, bradycardia) or local anaes- resuscitation of the mother
and fetus.274—276 The
thetic toxicity.262 best survival rate for
infants over 24—25 weeks’
gestation occurs when
delivery of the infant is
achieved within 5 min after
the mother’s cardiac
Cardiovascular disease
arrest.274,277—279 This
requires that the provider
Pulmonary hypertension causes most deaths from commence the hysterotomy at
about 4 min after
congenital heart disease. Peripartum cardiomyopa- cardiac arrest. Delivery
will relieve caval compres-
thy, myocardial infarction and aneurysm or dissec- sion and improve chances of
maternal resuscita-
tion of the aorta or its branches cause most deaths tion. The Caesarean delivery
also enables access
from acquired cardiac disease.263,264 Patients with to the infant so that
newborn resuscitation can
known cardiac disease need to be managed in a spe- begin.
cialist unit. Pregnant women with coronary artery
disease may suffer an acute coronary syndrome.
Percutaneous coronary intervention is the reperfu- Decision-making for
emergency hysterotomy
sion strategy of choice for ST-elevation myocardial
infarction in pregnancy because fibrinolytics are Consider gestational age.
The gravid uterus
relatively contraindicated.265 reaches a size that will
begin to compromise aorto-
caval blood flow at
approximately 20 weeks’ ges-
tation; however, fetal
viability begins at approx-
Pre-eclampsia and eclampsia
imately 24—25 weeks.
Portable ultrasounds are
Eclampsia is defined as the development of convul- available in some emergency
departments and may
sions and/or unexplained coma during pregnancy or aid in determination of
gestational age (in expe-
postpartum in patients with signs and symptoms of rienced hands) and
positioning, provided their use
pre-eclampsia.266,267 Magnesium sulphate is effec- does not delay the decision
to perform emergency
tive in preventing approximately half of the cases hysterotomy.280
of eclampsia developing in labour or immediately
postpartum in women with pre-eclampsia. • At gestational age <20
weeks, urgent Caesarean
delivery need not be
considered, because a
Life-threatening pulmonary embolism gravid uterus of this size
is unlikely to signifi-
cantly compromise maternal
cardiac output.
Successful use of fibrinolytics for massive, life- • At gestational age
approximately 20—23 weeks,
threatening pulmonary embolism in pregnant initiate emergency
hysterotomy to enable suc-
women has been reported.268—271 cessful resuscitation of
the mother, not survival
S162
J. Soar et al.
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citation from accidental hypothermia of 13.7 ◦ C with circu- research
initiatives and future directions [published cor-
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appears in Ann Emerg Med. 1993;22:759]. Ann
89. Danzl DF, Pozos RS, Auerbach PS, et al. Multicen- Emerg Med
1993;22(pt 2):324—49.
ter hypothermia survey. Ann Emerg Med 1987;16:1042— 108. Bouchama
A, Knochel JP. Heat stroke. N Engl J Med
55.
2002;346:1978—88.
90. Reuler JB. Hypothermia: pathophysiology, clinical settings, 109. Wappler
F. Malignant hyperthermia. Eur J Anaesthesiol
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2001;18:632—52.
91. Lefrant JY, Muller L, de La Coussaye JE, et al. Temperature 110. Ali SZ,
Taguchi A, Rosenberg H. Malignant hyperther-
measurement in intensive care patients: comparison of uri- mia. Best
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Resuscitation (2005) 67S1, S171—S180
0300-9572/$ — see front matter © 2005 European Resuscitation Council. All Rights
Reserved. Published by Elsevier Ireland Ltd.
doi:10.1016/j.resuscitation.2005.10.005
S172
P.J.F. Baskett et al.
When should the decision be reviewed? What reli- Who should decide not to
attempt
gious and cultural factors should be taken into con- resuscitation?
sideration?
This very grave decision
is usually made by the
senior doctor in charge
of the patient after appro-
What constitutes futility? priate consultations.
Decisions by committee are
impractical and have not
been shown to work,
Futility exists if resuscitation will be of no benefit and hospital management
personnel lack the train-
in terms of prolonging life of acceptable quality. It ing and experience on
which to base a judge-
is problematic that, although predictors for non- ment. Decisions by legal
authorities are fraught
survival after attempted resuscitation have been with delays and
uncertainties, particularly if there
published,14—17 none has been tested on an inde- is an adversarial legal
system, and should be sought
pendent patient sample with sufficient predictive only if there are
irreconcilable differences between
value, apart from end-stage multi-organ failure the parties involved. In
especially difficult cases,
with no reversible cause. Furthermore, studies on the senior doctor may
wish to consult his or her
resuscitation are particularly dependent on system own medical defence
society for a legal opinion.
factors such as time to CPR, time to defibrillation, Medical emergency
teams (METs), acting in
etc. These may be prolonged in any study but not response to concern about
a patient’s condi-
applicable to an individual case. tion from ward staff, can
assist in initiating the
Inevitably, judgements will have to be made, decision-making process
concerning DNAR (see Sec-
and there will be grey areas where subjective opin- tion 4a).20,21
ions are required in patients with heart failure and
severe respiratory compromise, asphyxia, major Who should be consulted?
trauma, head injury and neurological disease. The
age of the patient may feature in the decision but Although the ultimate
decision for DNAR should
is only a relatively weak independent predictor of be made by the senior
doctor in charge of the
outcome18,19 ; however, age is frequently associated patient, it is wise for
this individual to consult oth-
with a prevalence of comorbidity, which does have ers before making the
decision. Following the prin-
an influence on prognosis. At the other end of the ciple of patient autonomy
it is prudent, if possible,
scale, most doctors will err on the side of interven- to ascertain the
patient’s wishes about a resus-
tion in children for emotional reasons, even though citation attempt. This
must be done in advance,
the overall prognosis is often worse in children than when the patient is able
to make an informed
in adults. It is therefore important that clinicians choice. Opinions vary as
to whether such discussions
understand the factors which influence resuscita- should occur routinely
for every hospital admission
tion success. (which might cause undue
alarm in the majority
of cases) or only if the
diagnosis of a potentially
life-threatening
condition is made (when there is
What exactly should be withheld? a danger that the patient
may be too ill to make a
balanced judgement). In
presenting the facts to the
Do not attempt resuscitation (DNAR) means that, patient, the doctor must
be as certain as possible of
in the event of cardiac or respiratory arrest, CPR the diagnosis and the
prognosis and may seek a sec-
should not be performed; DNAR means nothing ond or third medical
opinion in this matter. It is vital
more than that. Other treatment should be con- that the doctor should
not allow personal life values
tinued, particularly pain relief and sedation, as to distort the discussion
—–in matters of acceptabil-
required. Ventilation and oxygen therapy, nutrition, ity of a certain quality
of life, the patient’s opinion
antibiotics, fluid and vasopressors, etc., are con- should prevail.
tinued as indicated, if they are considered to be It is considered
essential for the doctor to have
contributing to the quality of life. If not, orders not discussions with close
relatives and loved ones if at
to continue or initiate any such treatments should all possible. Whereas
they may influence the doc-
be specified independently of DNAR orders. tor’s decision, it should
be made clear to them that
DNAR orders for many years in many countries the ultimate decision
will be that of the doctor. It
were written by single doctors, often without con- is unfair and
unreasonable to place the burden of
sulting the patient, relatives or other health per- decision on the relative.
sonnel, but there are now clear procedural require- The doctor would also
be wise to discuss the
ments in many countries such as the USA, UK and matter with the nursing
and junior medical per-
Norway. sonnel, who are often
closer to the patient and
S174
P.J.F. Baskett et al.
Research
Breaking bad news and
bereavement
There are important ethical issues relating to counselling
undertaking randomized clinical trials for patients
in cardiac arrest who cannot give informed con- Breaking news of the
death of a patient to a rel-
sent to participate in research studies. Progress in ative is an unenviable
task. It is a moment that
improving the dismal rates of successful resuscita- the relative will
remember for ever, so it is very
tion will only come through the advancement of important to do it as
correctly and sensitively as
science through clinical studies. The utilitarian con- possible. It also places
a considerable stress on the
cept in ethics looks to the greatest good for the healthcare provider who
has this difficult duty. Both
greatest number of people. This must be balanced may need support in the
ensuing hours and days. It
with respect for patient autonomy, according to is salutatory that the
breaking of bad news is sel-
which patients should not be enrolled in research dom taught in medical
school or at postgraduate
studies without their informed consent. Over the level.1
past decade, legal directives have been introduced
into the USA and the European Union42,43 that place Contacting the family in
the case of death
significant barriers to research on patients dur- without the relatives
being present
ing resuscitation without informed consent from
the patient or immediate relative.44 There are If the relatives are not
present when the patient
data showing that such regulations deter research dies, they must be
contacted as soon as possible.
progress in resuscitation.45 It is indeed possible that The caller may not be
known to the relative and
these directives may in themselves conflict with must take great care to
ensure that his or her
the basic human right to good medical treatment identity is made quite
clear to the relative and,
as set down in the Helsinki Agreement.12 Research in turn, the caller must
make sure of the rela-
in resuscitation emanating from the USA has fallen tionship of the call
recipient to the deceased. In
dramatically in the last decade,46 and it appears many cases it is not
stated on the telephone that
very likely that the European Union will follow the patient has actually
died, unless the distance
suit as the rules bite there.47 The US authorities and travel time are
prolonged (e.g., the relative
have, to a very limited extent, sought to introduce is in another country).
Many find that it is better
methods of exemption,42 but these are still asso- to say that the patient
is seriously and critically
ciated with problems and almost insurmountable ill or injured and that
the relatives should come
difficulties.45 to hospital immediately,
so that a full explanation
S178
P.J.F. Baskett et al.
can be given face to face. It is wise to request that • relief (‘‘I am so glad
his suffering is over,’’ or
relatives to ask a friend to drive them to hospital, ‘‘He went suddenly—–
that is what he would have
and to state that nothing will be gained by driving wished’’);
at speed. When the relatives arrive they should be • anger with the patient
(‘‘I told him to stop smok-
greeted right away by a competent and knowledge- ing,’’ or ‘‘He was too
fat to play squash,’’ or
able member of staff, and the situation explained ‘‘Look at the mess he
has left me in’’);
immediately. Delays in being told the facts are • self-guilt (‘‘If only I
had not argued with him this
agonising. morning before he left
for work,’’ or ‘‘Why did I
not tell the doctor he
got chest pain?’’);
• anger with the medical
system (‘‘Why did the
Who should break the bad news to the ambulance take so
long?’’ or ‘‘The doctor was
relative? far too young and did
not know what he/she was
doing’’);
Gone are the days when it was acceptable for the
• uncontrollable wailing
and crying and anguish;
patronising senior doctor to delegate the breaking
• complete expressionless
catatonia.
of bad news to a junior assistant. Nowadays, it is
generally agreed that it is the duty of the senior It may be useful to
reassure the family that they
doctor or the team leader to talk to the relatives. did everything correctly,
such as calling for help and
Nevertheless, it is wise to be accompanied by an getting to the hospital
but, in the vast majority of
experienced nurse who may be a great comfort for cases, healthcare
providers are unable to restart
the patient (and indeed the doctor). the heart.
Some time may elapse
before conversation can
resume and, at this
stage, ask relatives if they have
Where and how should bad news be given? any questions about the
medical condition and the
The environment where bad news is given is vitally treatment given. It is
wise to be completely open
important. There should be a room set aside for and honest about this,
but always say ‘‘He did not
relatives of the seriously ill that is tastefully and suffer’’.
comfortably furnished, with free access to a tele- In the majority of
cases the relative will wish
phone, television and fresh flowers daily (which to see the body. It is
important that the body and
may be provided by the florist who runs the flower bedclothes are clean and
all tubes and cannulae
shop that is in most hospitals in Europe). are removed, unless these
are needed for post-
There are some basic principles to be followed mortem examination. The
image of the body will
when breaking bad news, that should be adhered to leave an impression on
the relative that will last for
if grave errors are to be avoided and the relative is ever. A post-mortem
examination may be required,
not to be discomforted. It is essential to know the and this should requested
with tact and sensitiv-
facts of the case and to make quite sure to whom ity, explaining that the
procedure will be carried
who you are talking. Body language is vital; always out by a professional
pathologist and will help to
sit at the same level as the patient and relative; determine the precise
cause of death.
do not stand up when they are sitting down. Make
sure you are cleanly dressed; wearing blood-stained Children
clothing is not good. Do not give the impression
that you are busy and in a hurry. Give the news Breaking bad news to
children may be perceived to
they are anxious to hear immediately, using the present a special
problem, but experience seems
words ‘‘dead’’ or ‘‘has died’’, ‘‘I am very sorry to to indicate that it is
better to be quite open and
have to tell you that your father/husband/son has honest with them, so
helping to dispel the night-
died’’. Do not leave any room for doubt by using marish fantasies that
children may concoct about
such phrases as ‘‘passed on’’ or left us’’ or ‘‘gone death. It is helpful to
contact the school, so that
up above’’. the teachers and fellow
pupils can be prepared to
Discussing the medical details comprehensively receive the child back
into the school environment
at this stage is not helpful; wait until they are asked with support and
sensitivity.
for. Touching may be appropriate, such as holding
hands or placing an arm on the shoulder, but people Closure
and customs vary and the doctor needs to be aware
of these. Do not be ashamed if you shed a tear your- In many cases this will
be the relative’s first
self. Allow time for the news to be assimilated by experience of death, and
help should be offered
the relative. Reactions may vary, including with the bewildering
administration of the official
European Resuscitation Council Guidelines for Resuscitation 2005
S179
21. The MERIT study investigators. Introduction of the medical 36. Robinson
SM, Mackenzie-Ross S, Campbell Hewson GL, Egle-
emergency team (MET) system: a cluster-randomised con- ston CV,
Prevost AT. Psychological effect of witnessed
trolled trial. Lancet 2005;365:2091—7.
resuscitation on bereaved relatives. Lancet 1998;352:614—7
22. Sovik O, Naess AC. Incidence and content of written guide-
[comment].
lines for ‘‘do not resuscitate’’ orders. Survey at six dif- 37. Baskett
PJF. The ethics of resuscitation. In: Colquhoun MC,
ferent somatic hospitals in Oslo. Tidsskr Nor Laegeforen Handley
AJ, Evans TR, editors. The ABC of resuscitation. 5th
1997;117:4206—9. ed.
London: BMJ Publishing Group; 2004.
23. Bonnin MJ, Pepe PE, Kimball KT, Clark Jr PS. Distinct cri- 38. Azoulay
E, Sprung CL. Family-physician interactions in the
teria for termination of resuscitation in the out-of-hospital intensive
care unit. Crit Care Med 2004;32:2323—8.
setting. JAMA 1993;270:1457—62. 39. Bouchner
H, Vinci R, Waring C. Pediatric procedures: do par-
24. Kellermann AL, Hackman BB, Somes G. Predicting the out- ents want
to watch? Pediatrics 1989;84:907—9.
come of unsuccessful prehospital advanced cardiac life sup- 40.
Resuscitation Council (UK) Project Team. Should relatives
port. JAMA 1993;270:1433—6. witness
resuscitation? London, UK: Resuscitation Council;
25. Steen S, Liao Q, Pierre L, Paskevicius A, Sjoberg T. Evaluation 1996.
of LUCAS, a new device for automatic mechanical compres- 41. Morag RM,
DeSouza S, Steen PA, et al. Performing procedures
sion and active decompression resuscitation. Resuscitation on the
newly deceased for teaching purposes: what if we
2002;55:285—99. were to
ask? Arch Intern Med 2005;165:92—6.
26. Naess A, Steen E, Steen P. Ethics in treatment deci- 42. US
Department of Health and Human Services. Protection of
sions during out-of-hospital resuscitation. Resuscitation human
subjects: informed consent and waiver of informed
1997;35:245—56. consent
requirements in certain emergency circumstances.
27. Joint Royal Colleges Ambulance Liaison Committee. Newslet- In: 61
Federal Register 51528 (1996) codified at CFR #50.24
ter 1996 and 2001. Royal College of Physicians: London. and
#46.408; 1996.
28. Doyle CJ, Post H, Burney RE, Maino J, Keefe M, Rhee KJ. Fam- 43. Fontaine
N, Rosengren B. Directive/20/EC of the European
ily participation during resuscitation: an option. Ann Emerg
Parliament and Council of 4th April 2001 on the approxima-
Med 1987;16:673—5. tion of
the laws, regulations and administrative provisions
29. Adams S, Whitlock M, Higgs R, Bloomfield P, Baskett PJ. of the
Member States relating to the implementation of
Should relatives be allowed to watch resuscitation? BMJ good
clinical practice in the conduct of trials on medical
1994;308:1687—92. products
for human use. Off J Eur Commun 2001;121:34—
30. Hanson C, Strawser D. Family presence during cardiopul- 44.
monary resuscitation: Foote Hospital emergency depart- 44. Lemaire
F, Bion J, Blanco J, et al. The European Union
ment’s nine-year perspective. J Emerg Nurs 1992;18:104—6. Directive
on Clinical Research: present status of imple-
31. Cooke MW. I desperately needed to see my son. BMJ mentation
in EU member states’ legislations with regard
1991;302:1023. to the
incompetent patient. Intensive Care Med 2005;31:
32. Gregory CM. I should have been with Lisa as she died. Accid 476—9.
Emerg Nurs 1995;3:136—8. 45. Nichol G,
Huszti E, Rokosh J, Dumbrell A, McGowan J, Becker
33. Boie ET, Moore GP, Brummett C, Nelson DR. Do parents want L. Impact
of informed consent requirements on cardiac
to be present during invasive procedures performed on their arrest
research in the United States: exception from consent
children in the emergency department? A survey of 400 par- or from
research? Resuscitation 2004;62:3—23.
ents. Ann Emerg Med 1999;34:70—4. 46. Mosesso
Jr VN, Brown LH, Greene HL, et al. Conducting
34. Boudreaux ED, Francis JL, Loyacano T. Family presence dur- research
using the emergency exception from informed con-
ing invasive procedures and resuscitations in the emergency sent: the
public access defibrillation (PAD) trial experience.
department: a critical review and suggestions for future
Resuscitation 2004;61:29—36.
research. Ann Emerg Med 2002;40:193—205. 47. Sterz F,
Singer EA, Bottiger B, et al. A serious threat to
35. Martin J. Rethinking traditional thoughts. J Emerg Nurs evidence
based resuscitation within the European Union.
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Resuscitation 2002;53:237—8.
Resuscitation (2005) 67S1, S181—S189
Introduction established
European Resuscitation Council (ERC)
course with
small-group (four to eight mem-
There are a variety of methods used for train- bers)
participation using interactive discussion and
ing in resuscitation. None are perfect and, in the hands-on
practice for skills and clinical scenar-
absence of frequent practice, retention of knowl- ios for problem-
solving and team leadership.13
edge and skills is suboptimal. The optimal inter- The ratio of
instructors to candidates should
val for retraining has not been established, but range from 1:3
to 1:6, depending on the type of
repeated refresher training at intervals of less than course.
6 months seems to be needed for most individuals Core
knowledge should be acquired by candi-
who are not undertaking resuscitation on a regular dates before the
course by study of the course
basis.1—12 manual or an
interactive CD designed for the pur-
pose. The course
should aim to produce an improve-
ment in
competence in the learner, and there
Objectives should be a test
of core knowledge and an ongoing
assessment of
practical skills and scenario manage-
The objective of training is to equip the learner ment.
Sophisticated manikins, simulators and vir-
with the ability to be able to undertake resuscita- tual reality
techniques may be incorporated into
tion in a real clinical situation at the level at which the scenario-
based training.14
they would be expected to perform, be they be lay For basic
life support (BLS) by lay people or first
bystander, first responder in the community or hos- responders,
home-based learning using a video or
pital, a healthcare professional working in an acute interactive CD
with a simple manikin may offer
area, or a member of the medical emergency or a valuable
alternative to traditional instructor-
cardiac arrest response team. based courses.15
—19 This method minimises candi-
date disruption
and instructor time and finances.
However, the
role of the instructor should not be
Methods underestimated
and, in addition to explaining situ-
ations that were
unforeseen on the original video
Training should follow the principles of adult edu- or CD, the
instructor can act as a role model
cation and learning. Generally this will mean an and provide
invaluable enthusiasm and motivation.
0300-9572/$ — see front matter © 2005 European Resuscitation Council. All Rights
Reserved. Published by Elsevier Ireland Ltd.
doi:10.1016/j.resuscitation.2005.10.006
S182
P.J.F. Baskett et al.
Current ALS instructors and ICs can teach and rillation. With a
supportive approach, the major-
assess on ILS courses. There is also a pilot project ity of candidates achieve
the course learning out-
underway to develop specific ILS instructors. There comes.
must be at least 1 instructor for every 6 can-
didates, with a maximum of 30 candidates on a Equipment
course.
The ILS course is designed
to be straightforward
Course format to run. Most courses are
conducted in hospitals
with small groups of
candidates (average 12 can-
The ILS course is delivered over 1 day and comprises didates). The course
requires lecture facilities and
lectures, hands-on skills teaching and cardiac- a skills teaching area for
each group of six candi-
arrest scenario teaching (CASTeach) using manikins. dates. There needs to be
at least one ALS manikin
The programme includes a number of options that for every six candidates.
The course should be suit-
allow instructors to tailor the course to their can- able for local needs.
Course centres should try
didate group. as far as possible to
train candidates to use the
equipment (e.g.,
defibrillator type) that is available
locally.
Course content
The course covers those skills that are most likely Course report and results
sheet
to result in successful resuscitation: causes and pre-
vention of cardiac arrest, starting CPR, basic airway A course report and the
results sheet are compiled
skills and defibrillation (AED or manual). There are by the course director and
filed with the National
options to include the teaching of the laryngeal Resuscitation Council and
the ERC.
mask airway and drug treatments during cardiac
arrest. Once all the skills have been covered, there
is a cardiac arrest demonstration by the instruc- The Advanced Life Support
(ALS) course
tors that outlines the first-responder role to the
candidates. This is followed by the CASTeach sta- The target candidates for
this course are doctors
tion where candidates practise. ILS candidates are and senior nurses working
in emergency areas of
not usually expected to undertake the role of the the hospital and those who
may be members of
team leader. Candidates should be able to start the medical emergency or
cardiac arrest teams.26
a resuscitation attempt and continue until more The course is also
suitable for senior paramedics
experienced help arrives. When appropriate, the and certain hospital
technicians. The ILS course is
instructor takes over as a resuscitation team leader. more suitable for first-
responder nurses, doctors
This is not always necessary, as in some scenarios who rarely encounter
cardiac arrest in their prac-
resuscitation may be successful before more expe- tice, and emergency
medical technicians. Up to 32
rienced help arrives. Set scenarios are used that candidates can be
accommodated on the course,
are adapted to the workplace and the clinical role with a ratio of at least 1
instructor for every 3 can-
of the candidate. didates. Up to a maximum
of 50% of the instructors
may be ICs. Groups for
teaching should not exceed
Assessment eight candidates and
should be six ideally. Each
instructor acts as a
mentor for a small group of can-
Candidate’s performances are assessed contin- didates. The course
normally lasts for two to two
uously and they must show their competence and a half days.
throughout the ILS course. There are no formal
testing stations, removing the threat associated Course format
with spot testing at the end of the course. Candi-
dates are sent the assessment forms with the pre- The course format has very
few formal lectures
course materials. The forms indicate clearly how (four), and teaching
concentrates on hands-on
their performance will be measured against a pre- skills, clinically based
scenarios in small groups with
determined criteria. Assessment on the ILS course emphasis on the team
leader approach and interac-
enables the candidate to see what is expected and tive group discussions.
Mentor/mentee sessions are
frame learning around achievement of these out- included, to allow
candidates to give and receive
comes. The following practical skills are assessed on feedback. Faculty meetings
are held at the begin-
the ILS course: airway management, BLS and defib- ning of the course and at
the end of each day of the
European Resuscitation Council Guidelines for Resuscitation 2005
S185
course. Social occasions, such as course and faculty Course report and results
sheet
dinners, add greatly to the course interaction and
enjoyment. A course report and the
results sheet are compiled
by the course director
and filed with the national
resuscitation council and
the ERC.
Course content
provider courses. In some, the MIMMS course is closed discussions and the
role and qualities of the
undertaken under the auspices of the ALSG, and instructor.
IPs from that course may take the GIC to qualify
as ICs for teaching that course. There should be a Assessment
maximum of 24 candidates, with a ratio of at least
1 instructor to 3 candidates. Instructors must all Each candidate has ongoing
assessment by the fac-
be fully experienced ERC instructors, not ICs. A key ulty throughout the course.
Candidates’ perfor-
person is the educator. Groups should not exceed six mances and attitudes are
discussed at the daily
candidates. The emphasis of the course is on devel- faculty meetings and
feedback is given as required.
oping instruction skills. Core knowledge of the orig- Successful candidates may
proceed to the status of
inal provider course is assumed. The course lasts for IC.
two to two and a half days.
Course venue and equipment
Course format
This is as for the original
provider course. If the
The course format is largely interactive. The edu- candidates come from mixed
backgrounds, then a
cator plays a key role and leads many of the discus- variety of equipment is
required.
sions and feedback. There is one formal lecture on
effective teaching and adult learning, conducted
by the educator. This lecture is interspersed with Course report and results
sheet
group activities. The remainder of the course is
A course report is compiled
by the course director
conducted in small group discussions and skill- and
and the educator. This and
the results sheet are
scenario-based hands-on sessions.
filed with the national
resuscitation council and the
Mentor/mentee sessions are included, and there
ERC.
is a faculty meeting at the beginning of the course
and at the end of each day.
18. Batcheller AM, Brennan RT, Braslow A, Urrutia A, Kaye W. 23. Smith GB,
Osgood VM, Crane S. ALERT—–a multiprofessional
Cardiopulmonary resuscitation performance of subjects over training
course in the care of the acutely ill adult patient.
forty is better following half-hour video self-instruction com-
Resuscitation 2002;52:281—6.
pared to traditional four-hour classroom training. Resuscita- 24. Smith GB,
Poplett N. Impact of attending a 1-day multi-
tion 2000;43:101—10.
professional course (ALERT) on the knowledge of acute care
19. Lynch B, Einspruch E, Nichol G, Becker L, Aufderheide T, Idris in
trainee doctors. Resuscitation 2004;61:117—22.
A. Effectiveness of a 30-minute CPR self-instruction program 25.
Featherstone P, Smith GB, Linnell M, Easton S, Osgood VM.
for lay responders: a controlled randomized study. Resusci- Impact of
a one-day inter-professional course (ALERTTM )
tation 2005;67:31—43. on
attitudes and confidence in managing critically ill adult
20. Sandroni C, Fenici P, Cavallaro F, Bocci MG, Scapigliati patients.
Resuscitation 2005;65:329—36.
A, Antonelli M. Haemodynamic effects of mental 26. Nolan J.
Advanced life support training. Resuscitation
stress during cardiac arrest simulation testing on 2001;50:9
—11.
advanced life support courses. Resuscitation 2005;66:39— 27. Buss PW,
McCabe M, Evans RJ, Davies A, Jenkins H. A survey
44. of basic
resuscitation knowledge among resident paediatri-
21. Soar J, Perkins GD, Harris S, Nolan JP. The immediate life cians.
Arch Dis Child 1993;68:75—8.
support course. Resuscitation 2003;57:21—6. 28. Carapiet
D, Fraser J, Wade A, Buss PW, Bingham R. Changes
22. Soar J, McKay U. A revised role for the hospital cardiac arrest in
paediatric resuscitation knowledge among doctors. Arch
team. Resuscitation 1998;38:145—9. Dis Child
2001;84:412—4.