Constant change is here to stay!
Resuscitation guidelines are changing again but not too much – more of a refinement than a redefinition. The guidelines are reviewed internationally every five years and in October the European Resuscitation Council (ERC) published its new 2010 Guidelines based on the international review of evidence. The annual ERC Conference becomes a major milestone every five years and well over 2000 delegates attended the 2010 Guidelines Conference in Oporto, Portugal, in December. The programme covered a wide range of topics, for example, resuscitation in adults and children, in the community and in hospital, in sport, drowning, avalanche, chemical attack, hyperthermia, poisoning, trauma and much more. The programme also covered the educational implications and new teaching techniques in simulation as well as some emerging treatment techniques, such as therapeutic hypothermia, to prolong survival. We were pleased to join in and hear about the changes first hand both from our own point of view and also to feed in relevant material to our training courses.
The main changes since the 2005 Guidelines include:
Improved recognition of cardiac arrest both from victim unresponsiveness and also the quality of the breathing (terminal or agonal gasps are often interpreted wrongly as a sign of life) – unresponsiveness and abnormal breathing when taken together should initiate cardiopulmonary resuscitation (CPR) and get help on the way. Giving chest compressions in the presence of a spontaneous circulation is not harmful and it is far better to over-react rather than watch a victim die without making an effort to help.
Chest compressions combined with rescue breaths remain unchanged at a ratio of 30:2 as the favoured method for cardiopulmonary resuscitation. However hands-only CPR is recommended if the rescuer is not trained or is not willing to give rescue breaths – telephone-guided compressions-only CPR is encouraged for untrained rescuers.
High quality chest compressions remain essential. The aim is now to compress the chest to a depth of 5-6cm (rather than 4-5cm) because this produces improved short term outcomes and outweighs the possible risk of injury to the victim. Monitoring devices that provide feedback to the rescuer about the quality of their efforts may be used to improve performance. Rescuers may overestimate the depth of compression when the victim is on a soft surface, such as a mattress, and firm ground or flooring offers the best surface for CPR.
Chest compressions should allow full chest recoil to allow the relaxing heart to refill with blood. Full chest recoil is achieved by not leaning on the chest during the relaxation phase and also by allowing approximately the same amount of time for compression as relaxation. The hands location is described more simply as “the centre of the chest” to avoid potentially confusing and time-wasting finer detail.
The compression rate should be 100-120 compressions per minute (previously “about 100 per minute”) which translates to at least 60 per minute after allowing for minimum interruptions for rescue breaths or application of the defibrillator. Five seconds are allowed for two effective breaths after every 30 chest compressions and CPR is encouraged right up to defibrillator shock and should be resumed immediately after shock delivery so that the interruption to chest compressions is again limited to five seconds.
Following cardiac arrest, immediate CPR can double or triple eventual survival. Performing hands-only CPR is better than giving no CPR at all. CPR plus defibrillation within 3-5 minutes of collapse can produce impressive survival rates but each minute of delay before defibrillation reduces the survival rates by 10-12%
Evidence was presented at the Conference on the poor retention time of lay and professional students and the need for frequent refresher training to optimise effective responses and to minimise confusion and panic. Current MCA recommendations on refresher courses for Elementary First Aid are limited to every three to five years and labour-intensive and time consuming refresher courses do not lend themselves to more frequent updating than this. There are some useful devices available for e-learning on personal computers and for easy revision programmes on i-phones. With some imagination, it should be possible to raise the general skill level throughout the yachting industry and we shall be trying to introduce suitable revision aids through our regular courses.
Dr Ken Prudhoe, MCA Approved Doctor, can be contacted at Club de Mar Medical Centre, Palma de Mallorca.