In today’s micro-lecture, Australian Paramedical College Hon. Snr. Lecturer Sam Willis talks about the key principles of basic life support including cardiac arrest and what is important for patient outcomes.
In this lecture we’re going to talk about the key principles of basic life support. Now, there’s no doubt that you will have already become comfortable and familiar with basic life support due to the readings that you’ve done, maybe you’ve done a course, maybe you’ve attended the workshops. Regardless, what we’re going to do in this lecture is to go over the key principles of basic life support. In other words, what is it about basic life support that is important to the patient outcomes?
Now, the other good news is if you’re just about to prepare to go to the workshops, the first workshop, then this is a really good lecture for you because these are the principles that are taught at the workshop. Those of you who have been to Workshop One and you’re preparing for Workshop Two, now in Workshop Two you will be doing advanced life support, but it doesn’t matter. It’s irrelevant because the principles of this lecture are exactly what we teach in Workshop Two. In other words, the principles of advanced life support are the same as basic life support, the difference being between the two is that you get to do more things during advanced life support.
Okay, so in this lecture we’re going to talk about the key principles of cardiac arrest management. Now, we’re talking about the key principles. There’s no doubt you will already know about danger response A, B, C, D, E and chest compressions. We’re going to go through that again, and we’re going to go through it in some detail up from two viewpoints, from the viewpoint of the paramedic and not just the first aider, and also from the viewpoint of the patient. In other words, what’s important to the patient.
We’re also going to recognise the links of the chain of survival and how they relate to patient care. The chain of survival really is where it’s all at. That’s really the guideline for this entire lecture. We’re going to go through each different link in the chain and talk about it in some detail.
Understand what effective CPR is. Now, time and time again you’ll hear effective, timely CPR. What does that actually mean? We’re going to talk through that and recognize how to safely defibrillate a patient. Now, the good news is defibrillation has become safer and safer over the years, but there’s still research being conducted as to how to make defibrillation more effective and more safe.
Okay, so let’s start by introducing you to them. Out-of-hospital cardiac arrest management remains a hot topic in paramedicine. Now, that’s because it comes with high costs. In other words, if you get it wrong or if you don’t respond quickly enough, or the conditions aren’t right, then it comes with the life costs. Now, as you will already know through the readings that you’ve done and the experiences that you’ve had, approximately 80% to 90% of paramedicine really isn’t acute, life-threatening emergencies. Rather chronic conditions that have flared up, that have been exacerbated by some kind of condition. Cardiac arrest management really is the opposite. Cardiac arrest management really is an acute situation that requires fast reactions, fast thinking, good communication, good team working, effective, high-quality CPR, early defibrillation.
This is the reason why, because the brain can only last without oxygen for three minutes. Depending on which book you read, some will say three minutes, some will say three to five minutes. Regardless of the text you read, after that time period the brain becomes irreversibly brain damaged and therefore death follows very shortly after.
Now, the even bigger problem is … Let’s say that it’s been a 10-minute period, nobody’s been doing CPR. You guys arrive on-scene. You do amazing high-quality CPR with advanced life support, and you do all the different things that you do. You provide cannulation and you give the adrenaline. You managed to get a cardiac output back, which has been shown to happen. Now unfortunately, if the brainstem is dead, in other words, no oxygen for three to five minutes, it doesn’t matter what you do that person will be permanently switched off when they get to hospital. In other words, you will continue to do what you do through your advanced life support protocols. You take them to hospital, they go up to intensive care, they’ll be put on a life support machine for a period of time, and then that’s it. After a certain amount of time, the life support will be switched off in consultation with the family.
Again, this idea of three to five minutes is so important and ties in so well with what we’re talking about here, basic life support. Now, I always say that you should never be put off by the word basic because high-quality CPR and early defibrillation are actually far from basic.
This is one situation. This is cardiac arrest management where the life of the patient hangs in the balance of the paramedics’ ability to provide rapid, high-quality care. Now there are a whole range of different things that can get in the way of rapid care, including crew working, how long it took for the person to call 000, and a whole range of other factors. Once you arrive on-scene, establishing that cardiac arrest is in progress is really, really important, and of course, providing that high-quality care once you’ve established it. Again, so important.
Management of a cardiac arrest patients does follow the D, R, A, B, C, D model. We’re going to talk about how they are adapted in the cardiac arrest situation. Here we have it then guys, the chain of survival. Highly likely you’ve seen this before, but let’s go through this together because this is really something that guides your care. Early recognition and call for help.
Now, I remember one Sunday morning when I was a paramedic in London and we got called for somebody who had collapsed in the street. Now, when we arrived on-scene, there was an off-duty soldier doing high-quality CPR and nothing was getting in his way of doing those chest compressions. Now I remember it very well because it was your typical British weather, it was overcast, cloudy, chucking it down with rain. When we arrived on-scene, there was this person doing really good CPR. Then when we arrived, we did everything we had to do. Continued the CPR, continued the advanced life support, high-quality CPR, early defibrillation, got them to hospital, and that patient ended up surviving.
We could honestly say that the only reason that patient ended up surviving was because of the off-duty person, the off-duty soldier doing the high-quality CPR. Early recognition and early call for help, yes, they are part of it, and as you can see here, early CPR. The next thing they did after calling for help was to get straight on that person’s chest. Then when we arrived, we … What CPR does is CPR is the holding tool it basically holds the person until the defibrillator arrives. In other words, it provides oxygenation up to the brain and the vital organs. Now, if the CPR is not high-quality, it doesn’t do that and it’s absolutely pointless.
Early defibrillation, so once you have established cardiac arrest, you’ve got on the chest, the next thing you do is get the defibrillator out. Now, it doesn’t matter whether you’re the bystander or whether you’re the paramedic, or you’re a doctor, or a nurse, this is what we teach. This is what is taught throughout the world. What we’re talking about here are directly from those guidelines, including the Australian Resuscitation Council Guidelines.
Now, let’s say we’ve had good-quality CPR before the paramedics arrived. You guys have arrived. Really good, high-quality CPR. You guys arrived with the defibrillators because let’s face it, the only thing that’s going to convert a shockable rhythm is a shock, an energy bolt of defibrillator. Let’s say we defibrillate, and we get the patient back. In other words, we get post-resuscitation, we return a spontaneous circulation. Therefore, we then have to do post-resuscitative care.
That’s what this last chain is about. Now, the notion of post-resuscitative care is really concerned with keeping the person laying on their back, not moving them, not sitting them up, providing airway, breathing, circulation support. Now, most ambulance service guidelines will actually give you a step-by-step guideline so for their paramedics. Whether you’re working in private industry or if you’re working in the state services, and it usually revolves around airway control, oxygenation. Some services will allow you to do a 12 lead and tell you to take them to a cath lab when they’re ready. Others would allow you to give adrenaline to raise their blood pressure if their blood pressure’s low and other services will allow you to give things like atropin if the patient’s bradycardic. If they’re bradycardic, adrenalin and other drugs that can help speed the … It’s really based around ABC.
Regardless of the post-resuscitative care the themes are, those are the themes where you’ve got to follow what your service tells you to do. You will always keep your patient laying flat unless absolutely necessary to move them out of those positions.
That’s the chain of survival. Get on the phone and get the help. Now at the workshop, you are the help so you are trained not to be the first aiders’ danger response, send for help. That’s first aid, that’s before you get to the workshop. When you get to the first workshop, you are the help. You need to try and adapt that to danger, response, airway, breathing, circulation while it’s actually airway, breathing, chest compressions, defibrillation. Then, of course, depending on where the situation goes, so we can get return of spontaneous circulation. What we’ve just said, keep them flat and get them to hospital as quickly as possible and do some vital signs on the way by continuous monitoring. If they don’t come around, just get a second crew, get to hospital as soon as possible and that’s basically it.
Okay. This is what I’ve just said. You will always need to check for danger and tell your tutor what you’re checking for. Checking for danger to myself, my patient, my colleague. Is there anything in the environment that could cause us harm? It doesn’t matter whether you a student, paramedic, a qualified paramedic, a doctor or a nurse. This is the primary survey. Response, “Hello. Can you hear me? Open your eyes.” Give them a shake, try and generate a response through the pressure of the trapezius muscle. Now under basic life support guidelines we don’t do a massive amount with the airway apart from opening it to get the tongue off the back of the throat. The reason being is we used to check for vomit and all these types of things and all you’re doing is delaying CPR and CPR is the priority.
Breathing, so check it, so look, listen, feel really, look down the chest, put your hand on the chest if you need to, keep the airway open. Feel for the chest rise and fall, and actually look for up to 10 seconds. Now in the Resuscitation Council Guidelines it says, if you want to check for a pulse, you can, but you don’t have to. Now, what the evidence has shown is that even experienced qualified nurses, doctors, paramedics, they struggle to palpate the carotic pulse under situations like this. You’ll need to take your guidance of your education person, your trainer when you get to the workshop, but the Australian Research Council Guidelines say, if you want to, you can, but it’s no longer than 10 seconds. Now, if you don’t want to, you don’t have to either, but you need to just justify to your trainer.
Checking for signs of life, checking for breathing. They’re not moving, they’re looking pale, they’re looking clammy, their lips are blue. The typical signs and symptoms that you would find with somebody in cardiac arrest. Now their breathing’s either absent or not normal. Therefore, under the guidelines, The Australian Resuscitation Council Guidelines, they are indicated for CPR.
As you can see here the C is chest compressions. Now, this part is really where it’s at. What you do from here onwards is so important. Basically, whenever you come off the chest, you need to be able to justify and defend your actions because if somebody is asking you to come off the chest or if there’s only two of you and there’s things getting in the way of you doing CPR, you have to be able to defend coming off the chest because it’s the high-quality CPR at the right rate, at the right depth that will really push the circulation, push the blood up to the brain. If you are distracted or if your CPA is not high-quality enough, then you are really going to be scrutinised for that.
This is something that is taught all around the world in the universities, in new advanced life support. When you’re doing your CPR, let’s get this mindset right now that it’s the CPR that’s crucial. Okay? Everything else is just not proven to save your patient’s life but high-quality CPR, which we’ll talk about in a moment, really has been proven to to bring your patient back. In fact, the only two things that have been proven to save your patient’s life are chest compressions and defibrillation.
This is what this looks like. The breathing, is the patient breathing? If they are breathing, then check the circulation and continue to try and get a response. If there is a circulation and there’s no response and there’s no signs of trauma, this is where you’d put your patient in the recovery position. Is the patient breathing and is it normal? No. Then get straight onto the chest. That’s just an extra aid, and extra visual aid to help you guys to think about what I’ve just said.
Once you’ve started CPR, the next thing you need to do is to put the defib pads on. Now the bit about if needed, that really relates to the defibrillation. Now in Workshop One, you are following an automated external defibrillator so you put the pads on. One here, one here. One on the patient’s right side, one on the patient’s left axilla. That’s something that you’ll be shown time and time again. Once you’ve turned it on and if it says, “Stand clear, charging, shock advised.” Then while it’s charging, you are able to get back on the chest, do high-quality CPR for that 15 seconds, and then come off the chest when you need to deliver that shock. Now don’t worry about charging while it’s telling you to stay off it just do a CPR while it’s charging. It’s completely safe to do so, many studies have proven this.
Once you’ve delivered the shock, then you will go around and you start using the oropharyngeal tube then do your bag valve mask connected BVM up to the oxygen, request a second crew. Do everything that you can, swap over every two minutes. Then once you’ve established that you can’t do anything more, make a decision as to, “Are we going to go to hospital or wait for that second crew?” Okay.
Now let’s talk about high-quality CPR. First and foremost, minimal time off the chest. Again, I can’t emphasise enough the fact that, that high-quality CPR is pushing blood up to the brain and for you guys to come off the chest is actually probably clinical negligence by today’s standards. Now, when we talk about high-quality CPR, this is what we mean. Arms should be locked with your fingers, either interlocked like this or twisted like this, or some other way that allows you to press hard on that chest, get nice and close to your patient. The closer you are, the more you’re going to be able to lean backwards and forwards.
Now the guidelines say push at a depth of about three to five centimetres that’s really hard to try and measure, but it’s nice and deep. Also allow the recoil as well to come up so you’re pressing down, but you’re also allowing it to recoil and come up as well. You’re compressing at a rate of about 100 to 120 compressions per minute. Effective communication is something that underpins all of this. You’re telling your crew, “Cycle one, cycle two, cycle three, cycle four, cycle five, one, two, three, four, five, six.” And just communicating. “Okay, let’s swap over.” The more communication, the better, the safer you are. Of course, you’re doing at a rate of 29, 30, one, two. Two breaths in one second, one, two.
The reason we say 30 to two for now is because more and more evidence is supporting the notion that we don’t need to take our hands off the chest to do the two. Far too often we’re giving the ventilation’s too slowly, and therefore the cerebral profusion pressure, the pressure going up to the brain is lost too quickly. In fact the process of doing CPR allows oxygenation to occur to the brain anyway, so we need to start really thinking hard about taking our hands off the chest. There’s more and more studies going on about that.
Now, hands in the center of the chest is a really, really important one because there are controversies over what means the center. Some say between the nipples, others say it doesn’t work. Just you apply some clinical judgment and try and apply them in the center of the chest.
CPR from the side, not the head. Time and time again, we see students coming into the college and they’re doing CPR from the head. Now I understand when there’s only one or two of you, you’ve got to try and do 30 compressions and BVM as well. The guidelines clearly say the most effective CPR occurs from the side. Especially given that we’re moving away from doing two breaths, you don’t need to actually be at the head anymore.
Now highly experienced paramedics can do that because they understand all of this stuff that we’re talking about. Not only do they understand it, but they’re able to put it into practice. I would say if you absolutely have to be at the head end, only do that if you’re an experienced credentialed paramedic, not somebody who’s trying to prove themselves. I say that because it’s one of the nontechnical capabilities, or nontechnical skills. Egotism and trying to prove yourself is something that will get in the way every time. If you’re a junior paramedic, always from the side because the guidelines have shown and the evidence has shown that the most high-quality CPR occurs from the side
Of course if you wanting to be that great paramedic, this is the stuff that will make you a good paramedic. Of course swapping over every two minutes is something we’ve already mentioned and it’s highly important. More and more research is coming out in this area and research has shown that after two minutes not only does your rate suffer so does your depth.
Now let’s talk briefly about defibrillation. Now we know that defibrillation is the only thing that will reverse a fibrillating heart, nothing else, not high-quality CPR. Certainly as the high-quality CPR has pushed that fibrillation into a holding pattern, but it’s only a large voltage of energy that will actually revert it. Now, just remember the AEDs can be used by untrained personnel. The idea is that you have a highly stressful situation in a public place and the public are able to go and get it. Open the AED, put the pads on, press the button, and it talks you through it.
Now that’s not you, you are doing this course and you’re definitely not untrained personnel. However, that means that you must be able to apply all of this stuff, keep calm, and always be safe. In other words, when it’s saying, “Press to shock.” You make sure you shout, “Stand clear.” Communicate effectively. Press the shock and then straight back on the chest without any thoughts, straight back. Of course, remembering that when you’re putting the pads on, you’re putting it onto clean skin making sure that you shave the chest if there’s lots of hair. You’re putting it on the pads nice and effectively. Remembering that only 30% of that shock gets to them to the sinoatrial node where it needs to go to. Putting them in the right position and giving that shock as quickly as possible. Don’t forget you need to defibrillate every two minutes, which is approximately five cycles at 30 to two. Once the AED has identified a shockable rhythm straight back on the chest afterwards. That’s what we’ve just said so straight back on the chest with no delays.
What we’ve talked about here guys is the key principles of cardiac arrest management, recognize the links of the chain of survival and understand what effective CPR is and how they relate back to the chance of survival and how to safely defibrillate a patient. Now, this short lecture really is just the tip of the iceberg when it comes to cardiac arrest management because it’s a hugely popular and common topic, but it’s something that you can read about in all the ALS guidelines and BLS guidelines, something that you’ll do in the workshops again.