Basic Life Support
Basic life support is the maintenance of an airway and the support of breathing and the circulation without using equipment other than a simple airway device or protective shield. A combination of expired air ventilation (rescue breathing) and chest compression is known as cardiopulmonary resuscitation (CPR), which forms the basis of modern basic life support.
The term "cardiac arrest" implies a sudden interruption of cardiac output, which may be reversible with appropriate treatment. It does not include the cessation of heart activity as a terminal event in serious illness; in these circumstances the techniques of basic life support are usually inappropriate.
Survival after cardiac arrest is most likely to be the outcome in the following circumstances: when the event is witnessed; when a bystander summons help from the emergency services and starts resuscitation; when the heart arrests in ventricular fibrillation; and when defibrillation and advanced life support are instituted at an early stage. Basic life support is one link in this chain of survival. It entails assessment followed by action the ABC: A is for assessment and airway, B is for breathing, and C is for circulation.
Adult basic life support.
Send or go for help as soon as possible according to guidelines.
Assessment
Rapidly assess any danger to the patient and yourself from hazards such as falling masonry, gas, electricity, fire, or traffic because there is no sense in having two patients. Establish whether the patient is responsive by gently shaking his or her shoulders and asking loudly "Are you all right?" Be careful not to aggravate any existing injury, particularly of the cervical spine.
Establishing responsiveness.
If no response is given, shout for help.
Airway
Establishing and maintaining an airway is the single most useful manoeuvre that the rescuer can perform.
Loosen tight clothing around the patient's neck. Extend, but do not hyperextend, the neck, thus lifting the tongue off the posterior wall of the pharynx. This is best achieved by placing your hand on the patient's upper forehead and exerting pressure to tilt the head. Remove any obvious obstruction from the mouth; leave well fitting dentures in place. Place two fingertips under the point of the chin to lift it forwards. This will often allow breathing to restart.
Look, listen, and feel for breathing: look for chest movement, listen close to the mouth for breath sounds, and feel for air with your cheek. Look, listen, and feel for 10 seconds before deciding that breathing is absent.
Recovery position
If the patient is unconscious but is breathing, place him or her in the recovery position. If necessary, support the chin to maintain an airway. In this position the tongue will fall away from the pharyngeal wall and any vomit or secretion will dribble out of the corner of the mouth rather than obstruct the airway or, later on, cause aspiration.
Turning casualty into the recovery position
Breathing
If breathing is absent, send a bystander to telephone for an ambulance. If you are on your own, go yourself. The exception to this rule is when the patient is a child or the cause of the patient's collapse is near drowning, drug or alcohol intoxication, trauma, or choking. Under these circumstances it is likely that you are dealing with a primary respiratory arrest and appropriate resuscitation should be given for about one minute before seeking help.
Return to the patient and maintain an airway by tilting the head and lifting the chin. Pinch the nose closed with the fingers of your hand on the forehead. Take a breath, seal your lips firmly around those of the patient, and breathe out until you see the patient's chest clearly rising. It is important for each full breath to last about two seconds. Lift your head away, watching the patient's chest fall, and take another breath of air. The chest should rise as you blow in and fall when you take your mouth away. Each breath should expand the patient's chest visibly but not cause overinflation as this will allow air to enter the oesophagus and stomach. Subsequent gastric distension causes not only vomiting but also passive regurgitation into the lungs, which often goes undetected.
If the patient is still not breathing after two rescue breaths (or after five attempts at ventilation, even if unsuccessful), check for signs of a circulation. Look and listen for any movement, breathing (other than an occasional gasp), or coughing. Take no more than 10 seconds to make your check.
Head tilt and jaw lift
Expired air resuscitationThe best pulse to feel in an emergency is the carotid pulse, but if the neck is injured the femoral pulse may be felt at the groin.
If you are a healthcare provider, and have been trained to do so, feel for a pulse as part of your check for signs of a circulation.
If no signs of a circulation are present continue with rescue breaths but recheck the circulation after every 10 breaths or about every minute.
Circulation
If there are no signs of a circulation (cardiac arrest) it is unlikely that the patient will recover as a result of CPR alone, so defibrillation and other advanced life support are urgently required. Ensure that the patient is on his or her back and lying on a firm, flat surface, then start chest compressions.
The correct place to compress is in the centre of the lower half of the sternum. To find this, and to ensure that the risk of damaging intra-abdominal organs is minimised, feel along the rib margin until you come to the xiphisternum. Place your middle finger on the xiphisternum and your index finger on the bony sternum above, then slide the heel of your other hand down to these fingers and leave it there. Remove your first hand and place it on top of the second. Press down firmly, keeping your arms straight and elbows locked. In an adult compress about 4-5 cm, keeping the pressure firm, controlled, and applied vertically. Try to spend about the same amount of time in the compressed phase as in the released phase and aim for a rate of 100 compressions/min (a little less than two compressions per second). After every 15 compressions tilt the head, lift the chin, and give two rescue breaths. Return your hands immediately to the sternum and give 15 further compressions, continuing compressions and rescue breaths in a ratio of 15:2. It may help to get the right rate and ratio by counting: "One, two, three, four ...."
If two trained rescuers are present one should assume responsibility for rescue breaths and the other for chest compression. The compression rate should remain at 100/min, but there should be a pause after every 15 compressions that is just long enough to allow two rescue breaths to be given, lasting two seconds each. Provided the patient's airway is maintained it is not necessary to wait for exhalation before resuming chest compressions.
Precordial thump
Studies have shown that an initial precordial (chest) thump may restart the recently arrested heart. This is particularly the case if the onset of cardiac arrest is witnessed.
Hand position for chest compression
The precordial thump is taught as a standard part of advanced life support.
Choking
A patient who is choking may have been seen eating or a child may have put an object into his or her mouth. Often the patient grips his or her throat with their hand.
If the patient is still breathing, he or she should be encouraged to continue coughing. If the flow of air is completely obstructed, or the patient shows signs of becoming weak, try to remove the foreign body from the mouth. If this is not successful give five firm back blows between the scapulae; this may dislodge the obstruction by compressing the air that remains in the lungs, thereby producing an upward force behind it. If this fails to clear the airway then try five abdominal thrusts. Make a fist of one of your hands and place it just below the patient's xiphisternum. Grasp this fist with your other hand and push firmly and suddenly upwards and posteriorly. Then alternate abdominal thrusts with back slaps.
Management of choking in adults.
If a choking patient becomes unconscious, this may result in the muscles around the larynx relaxing enough to allow air past the obstruction. If breathing does not resume, open the patient's airway by lifting the chin and tilting the head, and then attempt to give two effective rescue breaths. If this fails, start chest compressions, alternating 15 compressions with a further attempt to give rescue breaths. In this situation, the chest compressions are given to relieve airway obstruction rather than to circulate the blood as in cardiac arrest.
Choking and back blows
Abdominal thrusts in a conscious patient
Dangers of resuscitation
Until fairly recently the main concern in resuscitation was for the patient, but attention has now been directed towards the rescuer, particularly in the light of fears about the transmission of AIDS. However, no case of AIDS due to transfer from patient to rescuer (or vice versa) by mouth to mouth resuscitation has been reported. Despite the presence of the virus in saliva, it does not seem that transmission occurs via this route in the absence of blood to blood contact. Nevertheless, there is still concern about the possible risk of infection, and those who may be called on to administer resuscitation should be allowed to use some form of barrier device. This may take the form of a ventilation mask (for mouth to mask ventilation) or a filter device placed over the mouth and nose. The main requirement of these devices is that they should not hinder an adequate flow of air and not provide too large a dead space. Resuscitation must not be delayed while such a device is being sought.
The term "cardiac arrest" implies a sudden interruption of cardiac output, which may be reversible with appropriate treatment. It does not include the cessation of heart activity as a terminal event in serious illness; in these circumstances the techniques of basic life support are usually inappropriate.
Survival after cardiac arrest is most likely to be the outcome in the following circumstances: when the event is witnessed; when a bystander summons help from the emergency services and starts resuscitation; when the heart arrests in ventricular fibrillation; and when defibrillation and advanced life support are instituted at an early stage. Basic life support is one link in this chain of survival. It entails assessment followed by action the ABC: A is for assessment and airway, B is for breathing, and C is for circulation.
Adult basic life support.
Send or go for help as soon as possible according to guidelines.
Assessment
Rapidly assess any danger to the patient and yourself from hazards such as falling masonry, gas, electricity, fire, or traffic because there is no sense in having two patients. Establish whether the patient is responsive by gently shaking his or her shoulders and asking loudly "Are you all right?" Be careful not to aggravate any existing injury, particularly of the cervical spine.
Establishing responsiveness.
If no response is given, shout for help.
Airway
Establishing and maintaining an airway is the single most useful manoeuvre that the rescuer can perform.
Loosen tight clothing around the patient's neck. Extend, but do not hyperextend, the neck, thus lifting the tongue off the posterior wall of the pharynx. This is best achieved by placing your hand on the patient's upper forehead and exerting pressure to tilt the head. Remove any obvious obstruction from the mouth; leave well fitting dentures in place. Place two fingertips under the point of the chin to lift it forwards. This will often allow breathing to restart.
Look, listen, and feel for breathing: look for chest movement, listen close to the mouth for breath sounds, and feel for air with your cheek. Look, listen, and feel for 10 seconds before deciding that breathing is absent.
Recovery position
If the patient is unconscious but is breathing, place him or her in the recovery position. If necessary, support the chin to maintain an airway. In this position the tongue will fall away from the pharyngeal wall and any vomit or secretion will dribble out of the corner of the mouth rather than obstruct the airway or, later on, cause aspiration.
Turning casualty into the recovery position
Breathing
If breathing is absent, send a bystander to telephone for an ambulance. If you are on your own, go yourself. The exception to this rule is when the patient is a child or the cause of the patient's collapse is near drowning, drug or alcohol intoxication, trauma, or choking. Under these circumstances it is likely that you are dealing with a primary respiratory arrest and appropriate resuscitation should be given for about one minute before seeking help.
Return to the patient and maintain an airway by tilting the head and lifting the chin. Pinch the nose closed with the fingers of your hand on the forehead. Take a breath, seal your lips firmly around those of the patient, and breathe out until you see the patient's chest clearly rising. It is important for each full breath to last about two seconds. Lift your head away, watching the patient's chest fall, and take another breath of air. The chest should rise as you blow in and fall when you take your mouth away. Each breath should expand the patient's chest visibly but not cause overinflation as this will allow air to enter the oesophagus and stomach. Subsequent gastric distension causes not only vomiting but also passive regurgitation into the lungs, which often goes undetected.
If the patient is still not breathing after two rescue breaths (or after five attempts at ventilation, even if unsuccessful), check for signs of a circulation. Look and listen for any movement, breathing (other than an occasional gasp), or coughing. Take no more than 10 seconds to make your check.
Head tilt and jaw lift
Expired air resuscitationThe best pulse to feel in an emergency is the carotid pulse, but if the neck is injured the femoral pulse may be felt at the groin.
If you are a healthcare provider, and have been trained to do so, feel for a pulse as part of your check for signs of a circulation.
If no signs of a circulation are present continue with rescue breaths but recheck the circulation after every 10 breaths or about every minute.
Circulation
If there are no signs of a circulation (cardiac arrest) it is unlikely that the patient will recover as a result of CPR alone, so defibrillation and other advanced life support are urgently required. Ensure that the patient is on his or her back and lying on a firm, flat surface, then start chest compressions.
The correct place to compress is in the centre of the lower half of the sternum. To find this, and to ensure that the risk of damaging intra-abdominal organs is minimised, feel along the rib margin until you come to the xiphisternum. Place your middle finger on the xiphisternum and your index finger on the bony sternum above, then slide the heel of your other hand down to these fingers and leave it there. Remove your first hand and place it on top of the second. Press down firmly, keeping your arms straight and elbows locked. In an adult compress about 4-5 cm, keeping the pressure firm, controlled, and applied vertically. Try to spend about the same amount of time in the compressed phase as in the released phase and aim for a rate of 100 compressions/min (a little less than two compressions per second). After every 15 compressions tilt the head, lift the chin, and give two rescue breaths. Return your hands immediately to the sternum and give 15 further compressions, continuing compressions and rescue breaths in a ratio of 15:2. It may help to get the right rate and ratio by counting: "One, two, three, four ...."
If two trained rescuers are present one should assume responsibility for rescue breaths and the other for chest compression. The compression rate should remain at 100/min, but there should be a pause after every 15 compressions that is just long enough to allow two rescue breaths to be given, lasting two seconds each. Provided the patient's airway is maintained it is not necessary to wait for exhalation before resuming chest compressions.
Precordial thump
Studies have shown that an initial precordial (chest) thump may restart the recently arrested heart. This is particularly the case if the onset of cardiac arrest is witnessed.
Hand position for chest compression
The precordial thump is taught as a standard part of advanced life support.
Choking
A patient who is choking may have been seen eating or a child may have put an object into his or her mouth. Often the patient grips his or her throat with their hand.
If the patient is still breathing, he or she should be encouraged to continue coughing. If the flow of air is completely obstructed, or the patient shows signs of becoming weak, try to remove the foreign body from the mouth. If this is not successful give five firm back blows between the scapulae; this may dislodge the obstruction by compressing the air that remains in the lungs, thereby producing an upward force behind it. If this fails to clear the airway then try five abdominal thrusts. Make a fist of one of your hands and place it just below the patient's xiphisternum. Grasp this fist with your other hand and push firmly and suddenly upwards and posteriorly. Then alternate abdominal thrusts with back slaps.
Management of choking in adults.
If a choking patient becomes unconscious, this may result in the muscles around the larynx relaxing enough to allow air past the obstruction. If breathing does not resume, open the patient's airway by lifting the chin and tilting the head, and then attempt to give two effective rescue breaths. If this fails, start chest compressions, alternating 15 compressions with a further attempt to give rescue breaths. In this situation, the chest compressions are given to relieve airway obstruction rather than to circulate the blood as in cardiac arrest.
Choking and back blows
Abdominal thrusts in a conscious patient
Dangers of resuscitation
Until fairly recently the main concern in resuscitation was for the patient, but attention has now been directed towards the rescuer, particularly in the light of fears about the transmission of AIDS. However, no case of AIDS due to transfer from patient to rescuer (or vice versa) by mouth to mouth resuscitation has been reported. Despite the presence of the virus in saliva, it does not seem that transmission occurs via this route in the absence of blood to blood contact. Nevertheless, there is still concern about the possible risk of infection, and those who may be called on to administer resuscitation should be allowed to use some form of barrier device. This may take the form of a ventilation mask (for mouth to mask ventilation) or a filter device placed over the mouth and nose. The main requirement of these devices is that they should not hinder an adequate flow of air and not provide too large a dead space. Resuscitation must not be delayed while such a device is being sought.
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