Year 2000 Guidelines Analysis

Adult Basic Life Support

This report is based on final published BLS changes reported in 
Circulation Supplement for August 22, 2000. All readers are 
encouraged to read the findings for themselves-this review is not 
meant to be comprehensive nor should it substitute for a
BLS provider's own inquiry into these subjects, issues and 
recommendations. This material in Circulation represents a process 
of intensive review and consensus begun well over 18 months ago. 
A "roll out" is scheduled for September 21-24 in San Diego where 
this information will be further explained and how it will be 
incorporated in BLS changes will be presented. This, then represents 
the content that the San Diego conference will be based upon..

Chris Perrin, ACUTE CARE, INC. Director of Education

SEE ALSO: PBLS (Pediatric Basic Life Support)
PALS (Pediatric Advanced Life Support),
Ethical Aspects of CPR and ECC,
Post-Resuscitation, Acute Coronary Syndromes and CVA
and ACLS (Advanced Cardiac Life Support)

Adult Basic Life Support

Contents

Rescue Breathing

CPR

Regarding Compressions

The BLS Response

Stroke Management

Procedures

Disease Transmission

Rescue Breathing

• Without supplemental oxygen - target 10ml/kg (approx. 700-1000ml) for 2 seconds (class IIa);
• With at least supplemental oxygen of at least 40% concentration-ventilate with tidal volumes reduced to 6-7 ml/kg (approx. 400-600ml) for 1-2 seconds (Class IIb)

CPR

• Lay rescuers are not expected to do pulse checks (instead check for signs of circulation---coughing, breathing, or movement), though healthcare providers will continue to check for pulses;
• Lay rescuers will not be taught former procedure for unconscious patient with foreign body airway obstruction, instead they will perform CPR adding only an airway visualization step at ventilation steps;
• "untrained rescuers" should phone first in cases of a responsive victim with a foreign body airway obstruction;

Regarding Compressions

• Compression rate should be 100 per minute rather than the previous recommendation of 80-100 (Class IIb);
• Compression-ventilation ratio is 15:2 for both 1 and 2-rescuer CPR if patient is not intubated (Class IIb);
• Chest compression-no ventilation CPR okay for dispatcher-coached CPR and those that are unable/unwilling to ventilate (Class IIa);
• Audio prompts/metronomic coaching devices improve CPR (Class IIb);

The BLS Response

• For most victims of sudden nontraumatic cardiac arrest, "the time from collapse to defibrillation is the greatest determinant to survival."
• Some studies are now suggesting up to 15% of peds/adolescent cardiac arrest victims are in VT/VF;
• New exceptions to the 'phone first' rule for adults (over 8 years of age):
  • Submersion / near drowning
  • Trauma arrest
  • Drug overdose
• New exceptions to the 'phone fast' rule for children (under 8 years of age) will be cardiac arrest in cases with history of high risk of arrhythmias

Stroke Management

• The 7 D's
  • Out of hospital-Detect; Dispatch; Delivery (transport)
  • In hospital-Door (rapid triage upon arrival); Data (CT scan and diagnose type of stroke);
  • Decision (identify fibrolytic therapy candidates); Drug (treat with fibrolytic).
• Only half of stroke victims in US currently use EMS transport.
• 85% of strokes occur at home.

Procedures

• Recovery position (Class Indeterminate). If patient is in position for more than 30 minutes, turn patient to opposite side (for blood distribution, especially to dependent arm)
• Rescue breathing
  • Mouth-to-mouth-10-12 per minute ("one breath every 4-5 seconds");
  • Initial breaths-2 in US, 5 in Europe, Australia, and New Zealand;
  • Take a deep breath before each ventilation to maximize the oxygen content;
  • "Some evidence in animal models and limited adult clinical trials suggests that positive-pressure ventilation is not essential during the initial 6 to 12 minutes of adult CPR."
• Cricoid pressure
  • Apply "moderate rather than excessive" pressure in performing this.
• Pulse checks eliminated for lay public because of lengthy delays while checking and unreliable results of pulse checks
• Compressions
  • 15 consecutive compression preferred over 5 because more compressions actually occur per minute and greater intravascular pressures are generated with 15 compressions in a row-both lay public and healthcare providers should do this for two-person CPR in the non-intubated patient; alternative description for hand placement instruction to lay public-"…place heel of one hand in the center of the chest between the nipples."
  • Depress chest 1.5-2 inches, more in "large" patients…
  • Netherlands performs sequence "CAB" with compressions before airway and breathing; no data to show of CAB or ABC superior.

Disease Transmission

• 15 reports of CPR-related infection noted in the literature between 1960 and 1998. There were no reports of such infection in scientific journals between 1998 and 2000. Disease transmissions reported include Helicobacter pylori, Mycobacterium tuberculosis, meningococcus, herpes simplex, shigella, streptococcus, salmonella and neisseria gonorrhoeae.
• No reports of HIV, HBV, Hepatitis C, or cytomegalovirus.
• Face masks are more effective barriers than face shields. Despite the presence of one-way valves in face shields, one study cited bacterial contamination from the patient side to the rescuer side of the shield 6 out of 8 times

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