Honing your resuscitation 'chain of survival' skills
egistrars must be prepared for any eventuality in general practice. This makes cardiopulmonary resuscitation one of your most invaluable skills. It is a requirement of application for the MRCGP to have a valid certificate of competence in cardiopulmonary resuscitation. Guidelines for Resuscitation issued by the Resuscitation Council (UK) were implemented in 2001. All changes were made in order to enhance and strengthen the 'chain of survival'.
· Early access. Once absence of breathing has been identified the priority is to initiate a response from the emergency medical services by dialling 999 or the European-wide emergency number 112.
· Early CPR. CPR is intended merely as a 'holding' action and rarely results in return of a spontaneous circulation. Three to four minutes without a circulation will lead to irreversible cerebral damage and CPR is designed to slow down its onset. Furthermore it lengthens the window of opportunity for successful defibrillation. CPR buys time!
· Early defibrillation. In 'out of hospital arrests' suffered by adults, the largest proportion will initially present with a shockable rhythm (VF/VT) and the only effective means of correcting this is defibrillation. Every minute's delay can reduce survival by 10 per cent with very few successful defibrillation attempts after 10 minutes. Speed is therefore of the essence. The advent of automated external defibrillators makes early defibrillation a realistic possibility. They are extremely compact and easy to use, hence their appearance in public places such as railway stations, shopping centres and places of work.
· Advanced life support. Intubation, IV cannulation and continuous cardiac monitoring followed by immediate transportation to a suitable centre of care.
The primary survey
Your initial assessment will consist of the following sequence, the primary survey.
· Danger. Is it safe for you to be there? Angels fear to tread where doctors and nurses rush in.
· Response. Try to elicit a response from the casualty by shouting a command and gently squeezing the casualty's shoulders. Shout for help if no response elicited.
· Airway. Briefly inspect the mouth and remove any visible foreign bodies (do not perform blind finger sweeps). Leave well-fitting dentures in place. Place two fingers under the chin and a hand on the forehead and extend the airway (use jaw thrust if cervical injury suspected).
· Breathing. Check for up to 10 seconds. Can you feel a breath against your cheek, hear breathing or see chest movement? (Ignore occasional gasps, sighs or moans.)
If there is no breathing, activate the emergency medical services, preferably using someone else, such as whoever responded to your first shout for help, but if alone you have to do it.
Now deliver two effective ventilations. You must see chest movement occur to indicate effectiveness and in order to achieve this you can have five attempted ventilations to ensure two are effective
· Circulation. Check for a carotid pulse but also look for any other signs of a circulation has the casualty started to breath following the two ventilations or is there any movement. The carotid pulse check is unreliable hence the reason for it no longer being taught to first-aiders. Take no more than 10 seconds to assess for a circulation and if there is any doubt as to its presence move on to commence chest compressions.
Deliver 15 compressions at a rate of 100 per minute, compressing the chest 4-5cm. Now continue to alternate between two ventilations and 15 chest compressions. This continues until professional help arrives and takes over, you see signs of life, or you become too exhausted to continue. When a number of CPR-proficient rescuers are available, adult basic life support continues at the ratio of 15:2 as opposed to the previous two person ratio of 5:1. This is because studies have shown that 15:2 results in a longer period of perfusion and lessens the confusion when trying to remember what ratio to use.
In July 2001 the Resuscitation Council (UK) issued 'Cardiopulmonary Resuscitation Guidance for clinical practice and training in Primary Care'. The application of these guidelines will hopefully improve the standards of care received by those who require resuscitation outside of a hospital setting.
Approximately 60 per cent of those who arrest at home (and 75 per cent of those who arrest on surgery premises) subsequently survive to leave hospital after early defibrillation by their doctor which is why the guidelines state that every health care practice should be equipped with an automated external defibrillator and a sufficient number of staff trained in its use need to be available when patients are in the building.
The chain of survival