Resuscitation Council (UK)

Prehospital resuscitation

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1. The guideline process

The process used to produce the Resuscitation Council (UK) Guidelines 2015 has been accredited by the National Institute for Health and Care Excellence. The guidelines process includes:
  • Systematic reviews with grading of the quality of evidence and strength of recommendations. This led to the 2015 International Liaison Committee on Resuscitation (ILCOR) Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations.1,2
  • The involvement of stakeholders from around the world including members of the public and cardiac arrest survivors.
  • Details of the guidelines development process can be found in the Resuscitation Council (UK) Guidelines Development Process Manual. www.resus.org.uk/publications/guidelines-development-process-manual/
  • These Resuscitation Council (UK) Guidelines have been peer reviewed by the Executive Committee of the Resuscitation Council (UK), which comprises 25 individuals and includes lay representation and representation of the key stakeholder groups.

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2. Summary of changes in prehospital resuscitation since the 2010 Guidelines

  • The team approach is emphasised – the prehospital resuscitation team should ideally comprise four individuals, who between them undertake roles as team leader, manage the airway, and alternate in the delivery of chest compressions and assisting with vascular access and drug delivery.
  • Simpler airway devices such as supraglottic airways, including the laryngeal mask airway and i-gel, enable oxygenation and ventilation to be achieved rapidly. They should be used as part of a stepwise airway management pathway. Tracheal intubation should be attempted only by those with adequate training and only if simpler airways prove inadequate.
  • There is no evidence that a period of CPR before defibrillation improves success rates and solo responders arriving at a cardiac arrest should prioritise attaching a defibrillator and defibrillation if indicated.
  • Mechanical chest compression devices are a reasonable alternative to high quality manual chest compressions in situations where sustained high quality manual chest compressions are impractical or compromise provider safety.
  • The use of waveform capnography is emphasised not only to indicate correct placement of a tracheal tube in the airway (and not the oesophagus), but also as a useful indicator of cardiac output and the effectiveness of chest compressions. A sudden increase in the end-tidal carbon dioxide (CO2) may be an early indicator of return of spontaneous circulation (ROSC).
  • After ROSC is achieved, passive cooling is recommended in the prehospital phase.
  • The patient should be transferred to the most appropriate hospital for their needs, and this may not always be the nearest hospital. For patients with ST-segment elevation on the ECG the optimal care pathway requires direct transfer to a hospital that can provide immediate primary percutaneous coronary intervention (PPCI) at all times. An arrangement should be in place to receive these patients directly into the cardiac catheterisation laboratory.

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3. Introduction

The principles of basic and advanced life support are the same for the prehospital setting but can be limited by a combination of factors including a lack of trained staff, the setting (on scene or during transport), equipment and drugs and physical access to the patient. This section addresses specific prehospital issues that are not covered elsewhere in the Resuscitation Council (UK) Guidelines 2015.

  • These guidelines should be read in conjunction with the Resuscitation Council (UK) Resuscitation Guidelines 2015, Association of Ambulance Chief Executives (AACE) and Joint Royal Colleges Ambulance Liaison Committee (JRCALC) UK Ambulance Services Clinical Practice Guidelines,3 and local ambulance service protocols.
  • All doses of drugs and fluids refer to those appropriate for adults. Doses for children and the newborn should be modified accordingly.

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4. Dispatcher-assisted CPR

Scripted telephone triage is used in the UK to grade the urgency of emergency calls to the ambulance service and dispatch appropriate resources. This is an integral part of the Chain of Survival for cardiac arrest.4      
  
Dispatcher-assisted CPR reduces the time to first chest compression in out-of-hospital cardiac arrest (OHCA).5 Dispatcher-assisted CPR is considered beneficial and is now more practical with the widespread use of mobile phones, which enable the rescuer to receive instruction whilst staying with the victim,6,7 and is   enhanced with the ‘hands-free’ speaker phone function. Telephone instructions to the caller (rescuer) on how to give CPR increases the rate of bystander CPR and reduces the time in starting CPR, with some evidence that this improves outcome from cardiac arrest.7     

Dispatcher-assisted recognition of cardiac arrest     

In the UK, call handlers answering 999 calls generally have no medical training and read triage questions from a screen. The deviation allowed from the precise wording in the question or the advice supplied varies between dispatch systems. The wording of the questions and the instructions offered must be understood by both the caller and the dispatcher. Medical jargon must be avoided. Some systems allow the dispatcher flexibility in wording to clarify the meaning to the caller, but too much flexibility can cause ambiguity and delay starting dispatcher-assisted CPR.

The recognition of cardiac arrest is difficult over the telephone and is made more difficult as the caller is often distressed, alone and scared. 

Absence of breathing in an unconscious person is a good indicator of cardiorespiratory arrest, but many people with cardiac arrest initially gasp (agonal breathing) and the lay rescuer can misinterpret this as breathing.8  It is therefore considered better to ask if the victim is “breathing normally” instead of simply “breathing”. Some people with cardiac arrest will have an initial seizure when the heart stops. This can cause confusion and delay the correct diagnosis. 

  • Training of dispatchers should include the significance of agonal breathing. Dispatchers who understand this are more effective at recognising cardiac arrest.
  • Asking whether the person is a known epileptic can help reduce the risk of inadvertent CPR in a person having a seizure.9    
  • Dispatchers should be trained in the management of cardiac arrest in all age groups, so that they are familiar with the instructions that they are giving to the rescuer.
  • Dispatchers should be trained to handle very distressed callers.
  • Patients who are unconscious and not breathing normally should have the most rapid ambulance response possible.

Dispatcher advice

Following identification of cardiac arrest, dispatchers provide CPR instructions to the caller.10-12 This dramatically reduces the time to the first chest compression, compared with waiting for the arrival of an ambulance crew. However, delays in giving advice over the phone and/or poor quality CPR will limit these benefits.12            

  • Standardised dispatcher advice to bystanders is recommended to improve the prompt and correct recognition and treatment of cardiac arrest.
  • If the phone has a speaker facility, the caller should be told to switch it to speaker as this will facilitate continuous dialogue with the dispatcher including (if required) CPR instructions.13      

Dispatcher-assisted compression-only CPR

  • Dispatcher-assisted CPR should be easy to describe and easy to perform correctly, assisted by the use of a metronome  by the dispatcher to ensure correct compression rates.
  • When an untrained bystander dials 999, the ambulance dispatcher should instruct him to give chest-compression-only CPR while awaiting the arrival of trained help.
  • Bystanders who are trained and competent in CPR with rescue breathing should continue to undertake this, but only if they are confident to do so without dispatcher support.
Untrained rescuers receiving telephone advice are unable to do effective CPR combining rescue breaths and chest compressions.14,15 Rescuers may also be more likely to start CPR if they do not have to provide mouth-to-mouth breaths.16 Compression-only CPR is generally thought to be appropriate in most circumstances.       
     
In adults, dispatcher-assisted compression-only CPR produces better survival rates than conventional CPR.11,17,18 In children, where 70% of out-of-hospital cardiac arrests are associated with hypoxaemia, survival is improved if both chest compressions and rescue breaths are delivered.19,20 After cardiac arrest in children with a primary cardiac cause, there is no difference in survival after compression-only or conventional CPR – either technique produces better survival rates than no CPR.19,20  

Dispatcher-assisted use of automated external defibrillators (AEDs)

  • Community first responders, particularly in more rural areas and public access defibrillation schemes are important components of the initial response and should be established wherever possible.
  • Registration of defibrillators with the local ambulance services is highly desirable so that dispatchers can direct CPR providers to the nearest AED.
The Resuscitation Council (UK) adult basic life support and AED guidelines recommend that in order to improve survival from cardiac arrest: 
  1. All school children are taught CPR and how to use an AED.
  2. Everyone that is able to should learn CPR.
  3. Defibrillators are available in places where there are large numbers of people (e.g. airports, railway stations, shopping centres, sports stadiums), increased