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Basic life support
Essentials
- 1
A patient with sudden out-of-hospital cardiac arrest (OHCA) requires activation of the Chain of Survival, which includes early high-quality cardiopulmonary resuscitation (CPR) and early defibrillation. The emergency medical dispatcher plays a crucial and central role in this process.
- 2
Over telephone, the dispatcher should provide instructions for external chest compressions only CPR to any adult caller wishing to aid a victim of OHCA. This approach has shown absolute survival benefit and improved rates of bystander CPR.
- 3
In the out-of-hospital setting, bystanders should deliver chest compressions to any unresponsive patient with abnormal or absent breathing. Bystanders who are trained, able, and willing to give rescue breaths should do so without compromising the main focus on high quality of chest compressions.
- 4
Early defibrillation should be regarded as part of Basic Life Support (BLS) training, as it is essential to terminate ventricular fibrillation.
- 5
There is strong emphasis on the implementation of public-access defibrillation programs, which include the use of automated external defibrillators by untrained or minimally trained lay rescuers in public areas.
Introduction
Basic Life Support (BLS) aims to maintain respirations and circulation in the cardiac arrest victim. BLS’s major focus is on CPR with minimal use of ancillary equipment. It includes chest compressions with or without rescue breathing and defibrillation with a manual or automated external defibrillator (AED). BLS can be successfully performed immediately by any rescuer with little or no prior training or experience using dispatcher-assisted telephone instructions in the OHCA. BLS has proven value in aiding the survival of neurologically intact victims.
This chapter outlines an approach to BLS that can be delivered by any rescuer while awaiting the arrival of emergency medical services (EMS) or medical expertise able to provide Advanced Life Support (ALS) (see Chapter 1.2).
Chain of Survival
The Chain of Survival is the series of linked actions taken in treating a victim of sudden cardiac arrest. The first steps are early recognition of an individual at risk of or in active cardiac arrest and an immediate call to activate help from EMS. This is followed by early commencement of CPR with an emphasis on high-quality chest compressions and rapid defibrillation, which significantly improves the chances of survival from ventricular fibrillation (VF) in OHCA. CPR plus defibrillation within 3 to 5 minutes of collapse following VF in OHCA can produce survival rates as high as 49% to 75%. Each minute of delay before defibrillation reduces the probability of survival to hospital discharge by 10% to 12%. The final links in the Chain of Survival are effective ALS and integrated post-resuscitation care targeted at optimizing and preserving cardiac and cerebral function.
Development of protocols
Any guidelines for BLS must be evidence based and consistent across a wide range of providers. Many countries have established national committees to advise community groups, ambulance services and the medical profession of appropriate BLS guidelines. Box 1.1.1 lists the national associations that make up the International Liaison Committee on Resuscitation (ILCOR). The ILCOR group meets every 5 years to review the BLS and ALS guidelines and to evaluate the scientific evidence that may lead to changes.
Box 1.1.1
Membership of the International Liaison Committee on Resuscitation 2015
Revision of the Basic Life Support guidelines, 2015
The most recent revision of the BLS guidelines occurred in 2015 and followed a comprehensive evaluation of the scientific literature for each aspect of BLS. Evidence evaluation worksheets were developed and were then considered by ILCOR (available at http://circ.ahajournals.org/content/132/16_suppl_1/S40 ). The final recommendations were published in late 2015.
Australian Resuscitation Council and New Zealand Resuscitation Council Basic Life Support guidelines
Each national committee endorsed the guidelines with minor regional variations to take into account local practices. The recommendations of the Australian Resuscitation Council (ARC) combined with those of the New Zealand Resuscitation Council (NZRC) on BLS were published jointly in 2016 and are available at http://www.resus.org.au/policy/guidelines/ and http://www.nzrc.org.nz/guidelines/ respectively.
DRSABCD approach to Basic Life Support
A flowchart for the initial evaluation and provision of BLS for the collapsed patient is shown in Fig. 1.1.1 . This is based on a DRSABCD approach, the letters of which stand for D angers? R esponsive? S end for help; open A irway; normal B reathing? start C PR; and attach D efibrillator. This process therefore includes the recognition that a patient has collapsed and is unresponsive, a safe approach to checking for danger and immediately sending for help to activate the emergency medical response team. This is followed by opening the airway and briefly checking for abnormal or absent breathing, with rapid commencement of chest compressions and rescue breaths if the pulse is absent. A defibrillator is attached as soon as it is available, and prompts are followed if it is automatic or semiautomatic.
Change to the adult Basic Life Support in 2015
A significant change to the adult BLS in the ILCOR 2010 resuscitation guidelines was the recommendation for a Compressions, Airway, Breathing (CAB) sequence instead of an Airway, Breathing, Compressions (ABC) sequence. This was aimed at minimizing any delay in initiating chest compressions, particularly when the sudden collapse is witnessed and likely of cardiac origin. In the 2015 guidelines, the ILCOR task force differed from regional resuscitation councils in deciding to use the CAB or ABC sequence, as limited literature exists to make any single recommendation.
Regional variations
There are regional variations in the interpretation and incorporation of opening the airway within the BLS algorithm. In the European Resuscitation Council (ERC) and the ARC with the NZRC algorithm, opening the airway comes before assessment of breathing followed by compression if required. This effectively preserves the ABC sequence to avoid confusion, whereas the American Heart Association (AHA) Resuscitation Guidelines 2015 continue to advise a CAB sequence for CPR.
The ILCOR 2015 universal BLS algorithm with ARC and NZRC considerations is discussed in the remainder of this chapter.
Check for response and send for help
The patient who has collapsed is rapidly assessed to determine whether he or she is unresponsive and not breathing normally, indicating possible cardiorespiratory arrest. For an untrained rescuer, this can be sequentially assessed by a gentle ‘shake and shout’ and observation of the patient’s response rather than by looking specifically for signs of life (which was deemed potentially confusing). The rescuer can then assess the unresponsive patient for absent or inadequate breathing.
If cardiac arrest is assumed, the rescuer should immediately telephone the EMS (call first) and initiate chest compressions as advised by the dispatcher to initiate BLS care. A trained rescuer or health care provider may check for unresponsiveness and abnormal breathing at the same time and then activate the EMS or cardiac arrest team.
The health care rescuers may commence CPR with ventilation for approximately 2 minutes before calling the EMS (CPR first) when the collapse is due to suspected airway obstruction (choking) or inadequate ventilation (drowning, hanging, etc.) or for infants and children up to 18 years of age.
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