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Basic Life Support (BLS) & Cardiopulmonary Resuscitation (CPR) Clinical Guideline for General Practice Clinical Guideline

CL069
Version Number: Issued Date: Review Date: Sponsoring Director: Prepared By: Consultation Process: Formally Approved: Version 2; April 2011 18 April 2011 31 March 2013 Medical Director General Practice CPR Guideline Development Group Medical Director, Dr Kat Noble, Dr Ahmet Fuat, Dr Ian Davidson, Nursing and Clinical Quality Advisor 9 March 2011

Policy Adopted From: N/A Approval Given By: Senior Management Team, Medical Directorate

Document History
Version 2 Date April 2011 Significant Changes Amended section 4 to reflect the new Board arrangements

Equality Impact Assessment


Date Issues N/A

POLICY VALIDITY STATEMENT


This policy is due for review on the latest date shown above. After this date, policy and process documents may become invalid.

Policy users should ensure that they are consulting the currently valid version of the documentation.

Basic Life Support (BLS) & Cardiopulmonary Resuscitation (CPR) Clinical Guideline for General Practice Contents
Section Title
1 2 3 4 5 6 7 8 9 Introduction Definitions Guideline detail Duties And Responsibilities Implementation Training Implications Documentation Monitoring, Review And Archiving Equality Impact Assessment Statement

Page
3 4 5 6 6 7 7 8 9

Appendices
10 11 17

1 2 3

Chain of Survival BLS Guideline Defibrillator Guideline

BLS Required Equipment List

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Basic Life Support (BLS) & Cardiopulmonary Resuscitation (CPR) Clinical Guideline for General Practice 1. Introduction
NHS County Durham and Darlington aspires to the highest standards of corporate behaviour and clinical competence, to ensure that safe, fair and equitable procedures are applied to all organisational transactions, including relationships with patients their carers, public, staff, stakeholders and the use of public resources. In order to provide clear and consistent guidance, NHS County Durham and Darlington will develop documents to fulfil all statutory, organisational and best practice requirements and support the principles of equal opportunity for all. Sudden cardiac arrest, particularly from coronary heart disease remains one of the commonest causes of death in the United Kingdom. The Resuscitation Council (UK) advocates that the correct treatment must be given immediately if the patient is to have any chance of surviving. The interventions that contribute to a successful outcome after a cardiac arrest can be conceptualised as a chain the Chain of Survival. This is shown in appendix 1. The National Service Framework for Coronary Heart Disease recognises the importance of early defibrillation, it specifies that patients with symptoms of a heart attack should be attended to by someone trained and equipped to defibrillate within 8 minutes of calling for help to maximise the chance of successful defibrillation, should it be necessary. However, more recent Resuscitation Guidelines (Resuscitation Council (UK), 2010), states that an Automated External Defibrillator (AED) can be used safely and effectively without previous training; its use should not be restricted to trained rescuers. All employees of a GP practice may be required to resuscitate a victim of cardiopulmonary arrest. It is unacceptable for anyone who sustains a cardiopulmonary arrest to await the arrival of the ambulance service before basic resuscitation is performed and a defibrillator is available.

1.1

Status
This document is a clinical guideline developed for use by GP practice personnel and is based upon the latest national and international clinical evidence

1.2

Purpose and scope


This guideline aims to provide best practice relating to current resuscitation standards and training for those working in GP practices in NHS County Durham and Darlington. Although the persons most likely to attempt cardiopulmonary resuscitation (CPR) are general practitioners and nursing staff, all members of staff, including administrative staff may contribute directly or indirectly. Reception and administrative staff may make a very important contribution, as they often receive urgent calls and summon the emergency services. It is important to note that training and practice are necessary to acquire and maintain skills in CPR techniques. A consensus view, based on studies of comparable providers suggest that doctors and nurses should have refresher training in basic life support (BLS) and use of AED every twelve months. This guideline provides a framework which supports professional practice and advocates that all members of the practice are trained and equipped to resuscitate patients who suffer cardiopulmonary arrest. This guideline also aims to; reduce mortality and morbidity of those who have suffered a respiratory or cardiac arrest advocate that all employees of the GP practice are trained in BLS This guideline does not cover techniques which constitute Advanced Life Support (ALS) and does not cover anaphylaxis.

2.

Definitions
The following terms are used in this document: AED ALS BLS CAS Automated External Defibrillator Advanced Life Support Basic Life Support Central Alert System the system by which the Department of Health and PCT disseminate alerts relating to patient safety issues Cardiopulmonary resuscitation Do Not Attempt Attempt Resuscitation the term given to the notice relating to the circumstances when resuscitation of an individual should not be attempted Intermediate Life Support Paediatric Basic Life Support Primary Care Trust

CPR DNAR

ILS PBLS PCT

3.

Guideline detail
3.1 All staff members of the GP practice should be trained on an annual basis to resuscitate those who have a cardiopulmonary arrest using BLS/PBLS skills. Current guidelines from Resuscitation Council (UK) for the management of cardiopulmonary arrest must be followed. This clinical guideline also advocates that all staff members should be trained to use an AED. Rescuers begin CPR if the victim is unconscious or unresponsive and not breathing normally (ignoring occasional gasps). A single compression-ventilation (CV) ratio of 30:2 is used by the single rescuer of an adult or child (excluding newborn) out of hospital, and for all adult CPR. Specific guidelines relating to BLS (and PBLS) and the use of an AED are shown in appendices 2 and 3. 3.2 In the interests of patient safety, any GP or registered nurse who wishes to use ALS skills (including the administration of drugs) must be specifically trained to do so on an annual basis by an accredited provider. 3.3 Cardiopulmonary arrest occurring in general practice is recognised as a significant event/serious untoward incident and should be investigated as such any lessons learnt from the event should be implemented to prevent recurrence where possible. All staff must contribute to any cardiopulmonary arrest investigation and subsequent audit. 3.4 Resuscitation equipment is used relatively infrequently and therefore all staff must know where resuscitation equipment is kept and be trained on its use. Equipment should be checked on a weekly basis to ensure it is all present and in-date and a written/electronic copy of the check should be kept for validation purposes. All electronic equipment must be annually tested for safety reasons and replaced immediately if deemed to be not fit for use. A standard defibrillator sign should be placed at the location of the AED so that it is visible for all to see (the defibrillator sign is available from the Resuscitation Council (UK) website to download at http://www.resus.org.uk/pages/AEDsignP.htm). Please refer to appendix 4 for a list of recommended equipment for BLS and AED use. 3.5 Resuscitation equipment may, from time-to-time, be the subject of patient safety alerts. All GP practices must have electronic systems in place to be able to receive and implement patient safety alerts issued by the Central Alert Systems (CAS), via the PCT, within the timescales stipulated by the alert. 3.6 A DNAR decision applies specifically to CPR and to no other treatment. Patients for whom CPR will not prolong life, but may merely prolong the dying process, should be identified early and CPR should not be attempted on those where a DNAR decision has been made and where knowledge of the DNAR notice has been communicated and is apparent. However, CPR should not be withheld in cases where DNAR status is not known at the time of the

emergency. A standardised form should be used to record and communicate all DNAR decisions and DNAR decisions should be reviewed whenever clinically appropriate, but particularly when there is a significant change in the patients clinical condition or when the patient is transferred from one healthcare setting to another. Further guidance on DNAR and Advanced Decisions to Refuse Treatment (ADRT) are available via professional bodies.

4.
4.1

Duties and Responsibilities


The Board:
The Statutory Board has delegated responsibility to the Joint Board (JB) for setting the strategic context in which organisational process documents are developed, and for establishing a scheme of governance for the formal review and approval of such documents

4.2

Joint Chief Executive


The Joint Chief Executive has overall responsibility for the strategic direction and operational management, including ensuring that Trust process documents comply with all legal, statutory and good practice guidance requirements.

4.3

Medical Director
The Medical Director is the sponsoring director for this document and is responsible for ensuring that: This guideline reflects current national and international resuscitation evidence-based guidelines This guideline is updated when changes to the evidence-base occurs This guideline is disseminated to all GP practices

4.4

General Practice CPR Guideline Development Group


The General Practice CPR Guideline Development Group will:

Amend this guideline to reflect the latest clinical evidence

5.

Implementation
This guideline will be available to all GP practices within the geographical boundary of County Durham and Darlington for use in the circumstances described on the title page.

6.

Training Implications
It is recommended that all GP practice staff receive annual training on BLS and the use of AEDs. BLS training should be delivered by a training provider who is an accredited instructor with the Resuscitation Council (UK) and training must reflect current Resuscitation Council (UK) Guidance and European Resuscitation Council Guidelines and include both adult and paediatric BLS skills including;

the recognition of cardiopulmonary arrest the requirement to summon help instruction to start CPR using airway adjuncts and attempt defibrillation within 3 minutes of collapse.

AED training should include the following principles;


importance of an definition of defibrillation Resuscitation Council (UK) Guidance/protocols rhythm recognition recognition of cardiac arrest safety of the recipient of BLS, the operator and other personnel placement of electrodes demonstration of correct defibrillation technique practice allowing each student the time to run through at least one total procedure from start to finish cardiac arrest management scenarios to include BLS, airway management, cardiac arrest rhythm recognition and defibrillation pass Resuscitation Council (UK) competencies for automated external defibrillation

The GP practice will be responsible for co-ordinating CPR training provision. All new members of staff should have CPR training as part of their induction programme. Following training, all personnel must be able to demonstrate competence in all principles of training. Where competence is achieved, the trainer must provide evidence of completion of training for governance purposes. A record of staff who have completed training must be kept within the practice this should include the date on which staff receive training and the date on which they are due to receive re-training. Any GP or nurse who wishes to practice ALS/ILS techniques must receive annual training on ALS/ILS skills from a Resuscitation Council (UK) accredited provider.

7.
7.1

Documentation
Other related policy documents.
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NHS County Durham and Darlington, (2010) Policy for the Management and Reporting of Untoward Incidents and Near Misses (CO 009) NHS County Durham and Darlington, (2010) Policy and Procedure Guidance for the reporting of Serious Untoward Incidents (SUIs) (CG 001)

7.2

Legislation and statutory requirements


Cabinet Office, (1974) Health & Safety at Work etc Act, 1974, London Cabinet Office, (1999), Management of Health & Safety at Work Regulations, 1999, London Cabinet Office, (1995), The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations, 1995 (RIDDOR), London Cabinet Office, (1998), Human Rights Act, 1998, London Cabinet Office, (2001), Freedom of Information Act, 2001, London Cabinet Office, (2005), Mental Capacity Act, 2005, London Cabinet Office, (2007), MCA Code of Practice, 2007, London Cabinet Office, (2006), Equality Act, 2006, London

7.3

Best practice recommendations


European Resuscitation Council (2010), Resuscitation Guidelines, 2010. Resuscitation Council (UK), (2010), Resuscitation Guidelines. London: RC (UK) Department of Health. (2008) Records Management: NHS Code of Practice. London: DH. Department of Health (2000) National Service Framework Coronary Heart Disease. London: DH.

7.4

References
The major references consulted in preparing this document are described above.

8. Monitoring, Review and Archiving


8.1

Monitoring
The Medical Director, as sponsor director will agree with the General Practice CPR Guideline Development Group, a method for monitoring the dissemination and implementation of this guideline.

8.2

Review

8.2.1 The Medical Director will ensure that this document is reviewed in accordance with the timescale specified at the time of approval. No policy, procedure or

guideline will remain operational for a period exceeding three years without a review taking place. 8.2.2 Staff who become aware of changes in practice, changes to statutory requirements, revised professional or clinical standards and local/national directives that affect, or could potentially affect documents, should advise the sponsoring director as soon as possible, via line management arrangements. The sponsoring director will then consider the need to review the policy, procedure or guideline outside of the agreed timescale for revision. 8.2.3 If the review results in changes to the document, then the initiator should inform the policy manager who will renew the approval and re-issue under the next version number. If, however, the review confirms that no changes are required, the title page should be renewed indicating the date of the review and date for the next review and the title page only should be re-issued. 8.2.4 For ease of reference for reviewers or approval bodies, changes should be noted in the document history table on the front page of this document. NB: If the review consists of a change to an appendix or procedure document, approval may be given by the sponsor director and a revised document may be issued. Review to the main body of the guideline must always follow the original approval process. 8.3

Archiving
The Policy Manager will ensure that archived copies of superseded documents are retained in accordance with Records Management: NHS Code of Practice 2008.

Equality Impact Assessment Statement

Basic Life Support (BLS) & Cardiopulmonary Resuscitation (CPR) Clinical Guideline for General Practice Appendix 1

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Appendix 2 Basic Life Support (BLS) Guideline


Introduction Adult basic life support sequence Basic life support consists of the following sequence of actions: 1. Make sure the victim, any bystanders, and you are safe. 2. Check the victim for a response. Gently shake the victims shoulders and ask loudly, Are you all right? 3A. If the victim responds: Leave the victim in the position in which you find him/her provided there is no further danger. Try to find out what is wrong with the victim and get help if needed. Reassess the victim regularly. 3B. If the victim does not respond: Shout for help. Turn the victim onto his/her back and then open the airway using head tilt and chin lift: Place your hand on the victims forehead and gently tilt his/her head back. With your fingertips under the point of the victim's chin, lift the chin to open the airway. 4. Keeping the airway open, look, listen, and feel for normal breathing. Look for chest movement. Listen at the victim's mouth for breath sounds. Feel for air on your cheek. In the first few minutes after cardiac arrest, a victim may be barely breathing, or taking infrequent, noisy, gasps. This is often termed agonal breathing and must not be confused with normal breathing. Look, listen, and feel for no more than 10 s to determine if the victim is breathing normally. If you have any doubt whether breathing is normal, act as if it is not normal. 5A. If the victim is breathing normally: Turn the victim into the recovery position Summon help from the ambulance service by mobile phone. If this is not possible, send a bystander. Leave the victim only if no other way of obtaining help is possible.

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Continue to assess that breathing remains normal. If there is any doubt about the presence of normal breathing, start CPR (5B). 5B. If the victim is not breathing normally: Ask someone to call for an ambulance and bring an AED if available. If you are on your own, use your mobile phone to call for an ambulance. Leave the victim only when no other option exists for getting help. Start chest compression as follows: Kneel by the side of the victim. Place the heel of one hand in the centre of the victims chest (which is the lower half of the victims sternum (breastbone)). Place the heel of your other hand on top of the first hand. Interlock the fingers of your hands and ensure that pressure is not applied over the victim's ribs. Do not apply any pressure over the upper abdomen or the bottom end of the sternum. Position yourself vertically above the victim's chest and, with your arms straight, press down on the sternum 5 - 6 cm. After each compression, release all the pressure on the chest without losing contact between your hands and the sternum. Repeat at a rate of 100 - 120 min-1. Compression and release should take an equal amount of time. 6A. Combine chest compression with rescue breaths: After 30 compressions open the airway again using head tilt and chin lift. Pinch the soft part of the victims nose closed, using the index finger and thumb of your hand on his/her forehead. Allow the victims mouth to open, but maintain chin lift. Take a normal breath and place your lips around the victims mouth, making sure that you have a good seal. Blow steadily into the victims mouth whilst watching for his/her chest to rise; take about one second to make his/her chest rise as in normal breathing; this is an effective rescue breath. Maintaining head tilt and chin lift, take your mouth away from the victim and watch for his/her chest to fall as air comes out. Take another normal breath and blow into the victims mouth once more to give a total of two effective rescue breaths. The two breaths should not take more than 5 s. Then return your hands without delay to the correct position on the sternum and give a further 30 chest compressions. Continue with chest compressions and rescue breaths in a ratio of 30:2. Stop to recheck the victim only if he/she starts to show signs of regaining consciousness, such as coughing, opening his/her eyes, speaking, or moving purposefully AND starts to breathe normally; otherwise do not interrupt resuscitation. If the initial rescue breath of each sequence does not make the chest rise as in normal breathing, then, before your next attempt: Check the victim's mouth and remove any visible obstruction. Recheck that there is adequate head tilt and chin lift.

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Do not attempt more than two breaths each time before returning to chest compressions. If there is more than one rescuer present, another should take over CPR about every 1-2 min to prevent fatigue. Ensure the minimum of delay during the changeover of rescuers, and do not interrupt chest compressions. 6B. Compression-only CPR If you are not trained to, or are unwilling to give rescue breaths, give chest compressions only. If chest compressions only are given, these should be continuous at a rate of 100 120 min-1. Stop to recheck the victim only if he/she starts to show signs of regaining consciousness, such as coughing, opening his eyes, speaking, or moving purposefully AND starts to breathe normally; otherwise do not interrupt resuscitation. 7. Continue resuscitation until: qualified help arrives and takes over, the victim starts to show signs of regaining consciousness, such as coughing, opening his/her eyes, speaking, or moving purposefully AND starts to breathe normally, OR you become exhausted.

Further points related to basic life support Risks to the rescuer and victim The safety of both the rescuer and victim are paramount during a resuscitation attempt. There have been few incidents of rescuers suffering adverse effects from undertaking CPR, with only isolated reports of infections such as tuberculosis (TB) and severe acute respiratory distress syndrome (SARS). Transmission of HIV during CPR has never been reported. There have been no human studies to address the effectiveness of barrier devices during CPR; however, laboratory studies have shown that certain filters, or barrier devices with one-way valves, prevent transmission of oral bacteria from the victim to the rescuer during mouth-to-mouth ventilation. Rescuers should take appropriate safety precautions where feasible, especially if the victim is known to have a serious infection such as TB or SARS. During an outbreak of a highly infectious condition (such as SARS), full protective precautions for the rescuer are essential.

Initial rescue breaths During the first few minutes after non-asphyxial cardiac arrest the blood oxygen content remains high. Therefore, ventilation is less important than chest compression at this time. It is well recognised that skill acquisition and retention are aided by simplification of the BLS sequence of actions. It is also recognised that rescuers are frequently unwilling to carry out mouth-to-mouth ventilation for a variety of reasons, including fear of infection and distaste for the procedure. For these reasons, and to
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emphasise the priority of chest compressions, it is recommended that, in adults, CPR should start with chest compressions rather than initial ventilations.

Jaw thrust The jaw thrust technique is not recommended for lay rescuers because it is difficult to learn and perform. Therefore, the lay rescuer should open the airway using a head-tilt chin- lift manoeuvre for both injured and non-injured victims.

Agonal gasps Agonal gasps are present in up to 40% of cardiac arrest victims. Therefore laypeople should 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 in the first few minutes after sudden cardiac arrest; they are an indication for starting CPR immediately and should not be confused with normal breathing.

Use of oxygen during basic life support There is no evidence that oxygen administration is of benefit during basic life support in the majority of cases of cardiac arrest before healthcare professionals are available with equipment to secure the airway. Its use may lead to interruption in chest compressions, and is not recommended, except in cases of drowning.

Mouth-to-nose ventilation Mouth-to-nose ventilation is an effective alternative to mouth-to-mouth ventilation. It may be considered if the victims mouth is seriously injured or cannot be opened, if the rescuer is assisting a victim in the water, or if a mouth-to-mouth seal is difficult to achieve.

Chest compression In most circumstances it will be possible to identify the correct hand position for chest compression without removing the victims clothes. If in any doubt, remove outer clothing. Each time compressions are resumed on an adult, the rescuer should place his/her hands on the lower half of the sternum. It is recommended that this location be taught in a simple way, such as place the heel of your hand in the centre of the chest with the other hand on top. This teaching should be accompanied by a demonstration of placing the hands on the lower half of the sternum. Use of the internipple line as a landmark for hand placement is not reliable.

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Performing chest compression: a. Compress the chest at a rate of 100-120 min-1. b. Each time compressions are resumed, place your hands without delay in the centre of the chest (see above). c. Pay attention to achieving the full compression depth of 5-6 cm (for an adult). d. Allow the chest to recoil completely after each compression. e. Take approximately the same amount of time for compression and relaxation. f. Minimise interruptions in chest compression. g. Do not rely on a palpable carotid or femoral pulse as a gauge of effective arterial flow. h. Compression rate refers to the speed at which compressions are given, not the total number delivered in each minute. The number delivered is determined not only by the rate, but also by the number of interruptions to open the airway, deliver rescue breaths, and allow AED analysis.

Compression-only CPR Studies have shown that compression-only CPR may be as effective as combined ventilation and compression in the first few minutes after non-asphyxial arrest. However, chest compression combined with rescue breaths is the method of choice for CPR by trained lay rescuers and professionals and should be the basis for layrescuer education. Lay rescuers who are unable or unwilling to provide rescue breaths, should be encouraged to give chest compressions alone. When advising untrained laypeople by telephone, ambulance dispatchers should give instruction on compression-only CPR.

Paediatric Basic Life Support (BLS)


Many children do not receive resuscitation because potential rescuers fear causing harm. This fear is unfounded; it is far better to use the adult BLS sequence for resuscitation of a child than to do nothing. For ease of teaching and retention, laypeople should be taught to use the adult sequence for children who are not responsive and not breathing normally, with the single modification that the chest should be compressed by one third of its depth. However, the following minor modifications to the adult sequence will make it even more suitable for use in children: Give 5 initial rescue breaths before starting chest compressions (adult BLS sequence of actions). If you are on your own, perform CPR for 1 min before going for help. Compress the chest by one third of its depth. Use two fingers for an infant under 1 year; use one or two hands for a child over 1 year as needed to achieve an adequate depth of compression.

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Adult Basic Life Support (BLS) algorithm


UNRESPONSIVE?

Paediatric BLS algorithm

UNRESPONSIVE?

Shout for help

Shout for help

Open airway

Open airway

NOT BREATHING NORMALLY?

NOT BREATHING NORMALLY?

Call 999

If alone, perform 1 minute BLS as below prior to calling 999

30 chest compressions

5 initial rescue breaths and then 30 chest compressions

2 rescue breaths 30 compressions

2 rescue breaths 30 compressions

Call 999 if not already done so

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Appendix 3 Defibrillation Guideline


Introduction In the UK approximately 30,000 people sustain cardiac arrest outside hospital and are treated by emergency medical services (EMS) each year. Electrical defibrillation is well established as the only effective therapy for cardiac arrest caused by ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT). The scientific evidence to support early defibrillation is overwhelming; the delay from collapse to delivery of the first shock is the single most important determinant of survival. If defibrillation is delivered promptly, survival rates as high as 75% have been reported. The chances of successful defibrillation decline at a rate of about 10% with each minute of delay; basic life support will help to maintain a shockable rhythm but is not a definitive treatment. All AEDs analyse the victims ECG rhythm and determine the need for a shock. The semi-automatic AED indicates the need for a shock, which is delivered by the operator, while the fully automatic AED administers the shock without the need for intervention by the operator.

Sequence of actions for AED The following sequence applies to the use of both semi-automatic and automatic AEDs in a victim who is found to be unconscious and not breathing normally. 1. Follow the adult BLS sequence. Do not delay starting CPR unless the AED is available immediately. 2. As soon as the AED arrives: If more than one rescuer is present, continue CPR while the AED is switched on. If you are alone, stop CPR and switch on the AED. Follow the voice / visual prompts. Attach the electrode pads to the patients bare chest. Ensure that nobody touches the victim while the AED is analysing the rhythm. 3A. If a shock is indicated: Ensure that nobody touches the victim. Push the shock button as directed (fully-automatic AEDs will deliver the shock automatically). Continue as directed by the voice / visual prompts. Minimise, as far as possible, interruptions in chest compression. 3B. If no shock is indicated: Resume CPR immediately using a ratio of 30 compressions to 2 rescue breaths.

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Continue as directed by the voice / visual prompts. 4. Continue to follow the AED prompts until: qualified help arrives and takes over OR the victim starts to show signs of regaining consciousness, such as coughing, opening his/her eyes, speaking, or moving purposefully AND starts to breathe normally OR you become exhausted.

Placement of AED pads Place one AED pad to the right of the sternum (breast bone), below the clavicle (collar bone). Place the other pad in the left mid-axillary line, approximately over the position of the V6 ECG electrode. It is important that this pad is placed sufficiently laterally and that it is clear of any breast tissue. Although most AED pads are labelled left and right, or carry a picture of their correct placement, it does not matter if their positions are reversed. It is important to teach that if this happens in error, the pads should not be removed and replaced because this wastes time and they may not adhere adequately when re-attached. The victims chest must be sufficiently exposed to enable correct pad placement. Chest hair will prevent the pads adhering to the skin and will interfere with electrical contact. Shave the chest only if the hair is excessive, and even then spend as little time as possible on this. Do not delay defibrillation if a razor is not immediately available.

Defibrillation if the victim is wet As long as there is no direct contact between the user and the victim when the shock is delivered, there is no direct pathway that the electricity can take that would cause the user to experience a shock. Dry the victims chest so that the adhesive AED pads will stick and take particular care to ensure that no one is touching the victim when a shock is delivered.

Defibrillation in the presence of supplemental oxygen There are no reports of fires caused by sparking where defibrillation was delivered using adhesive pads. If supplemental oxygen is being delivered by a face mask, remove the face mask and place it at least one metre away before delivering a shock. Do not allow this to delay shock delivery.

Minimise interruptions in CPR The importance of early, uninterrupted chest compressions is emphasised. Interrupt CPR only when it is necessary to analyse the rhythm and deliver a shock. When two rescuers are present, the rescuer operating the AED applies the electrodes while the

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other continues CPR. The AED operator delivers a shock as soon as the shock is advised, ensuring that no one is in contact with the victim.

CPR before defibrillation Provide good quality CPR while the AED is brought to the scene. Continue CPR whilst the AED is turned on, then follow the voice and visual prompts. Giving a specified period of CPR, as a routine before rhythm analysis and shock delivery, is not recommended.

Voice prompts The sequence of actions and voice prompts provided by an AED are usually programmable and it is recommended that they be set as follows:

deliver a single shock when a suitable rhythm is detected; no rhythm analysis immediately after the shock; a voice prompt for resumption of CPR immediately after the shock; a period of 2 min of CPR before further rhythm analysis.

AED use by healthcare professionals


All healthcare professionals should consider the use of an AED to be an integral component of BLS. Early defibrillation should be available throughout all clinics. The Resuscitation Council (UK) advises that untrained employees working in healthcare establishments not be prevented from using an AED if they are confronted with a patient in cardiac arrest. The administration of a defibrillatory shock should not be delayed while waiting for more highly trained personnel to arrive. The same principle should apply to individuals whose certified period of qualification has expired.

Storage and use of AEDs AEDs should be stored in locations that are immediately accessible to rescuers; they should not be stored in locked cabinets as this may delay deployment. Use of the UK standardised AED sign is encouraged, to highlight the location of an AED. People with no previous training have used AEDs safely and effectively. While it is highly desirable that those who may be called upon to use an AED should be trained in their use, and keep their skills up to date, circumstances can dictate that no trained operator (or a trained operator whose certificate of training has expired) is present at the site of an emergency. Under these circumstances no inhibitions should be placed on any person willing to use an AED.

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Children Standard AED pads are suitable for use in children older than 8 years. Special paediatric pads, that attenuate the current delivered during defibrillation, should be used in children aged between 1 and 8 years if they are available; if not, standard adult-sized pads should be used. The use of an AED is not recommended in children aged less than 1 year. However, if an AED is the only defibrillator available its use should be considered (preferably with the paediatric pads described above).

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AED algorithm
UNRESPONSIVE? Call for help Open airway Not breathing normally Send or go for AED Call 999 CPR 30:2 Until AED is attached

AED assesses rhythm

Shock advised

No shock advised

1 shock

Immediately resume CPR 30:2 for 2 minutes

Immediately resume CPR 30:2 for 2 minutes

Continue until the victim starts to wake up, i.e. moves, opens eyes and breathes normally

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Appendix 4
BLS Required Equipment List
Automated Defibrillator (AED) Pocket Mask and one way valve. X 1 Spare AED Battery X 2 Packets of Sealed Pads X 2 disposable razors Scissors to cut clothing if required Gloves (Latex Free)

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