Adult Basic Life Support UNRESPONSIVE ? Shout for help Open airway NOT BREATHING NORMALLY ? Call 999 30 chest compressions 2 rescue breaths 30 compressions

To aid teaching and learning, the sequence of actions has been simplified. In some cases, simplification has been based on recently published evidence; in others there was no evidence that the previous, more complicated, sequence had any beneficial effect on survival. There are other changes in the guidelines. In particular, allowance has been made for the rescuer who is unable or unwilling to perform rescue breathing. It is well recorded that reluctance to perform mouth-to-mouth ventilation, in spite of the lack of evidence of risk, inhibits many would-be rescuers from attempting any form of resuscitation. These guidelines encourage chest compression alone in such circumstances. Guidelines 2000 introduced the concept of checking for ‘signs of a circulation’. This change was made because of the evidence that relying on a check of the carotid pulse to diagnose cardiac arrest is unreliable and time-consuming, mainly, but not exclusively, when attempted by non-healthcare professionals.4 Subsequent studies have shown that checking for breathing is also prone to error, particularly as agonal gasps are frequently misdiagnosed as normal breathing.5 In Guidelines 2005 the absence of breathing, in a non-responsive victim, continues to be the main sign of cardiac arrest. Also highlighted is the need to identify agonal gasps as another, positive, indication to start CPR. Finally, there is recognition that delivering chest compressions is tiring. It is now recommended that, where more than one rescuer is present, another should take over the compressions (with a minimum of delay) about every 2 min to prevent fatigue and maintain the quality of performance.

Adult BLS 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 his shoulders and ask loudly, ‘Are you all right?’ 3 A If he responds:       Leave him in the position in which you find him provided there is no further danger.      Try to find out what is wrong with him and get help if needed.      Reassess him regularly. 3 B If he does not respond:        Shout for help.          Turn the victim onto his back and then open the airway using head tilt and chin lift:                 o Place your hand on his forehead and gently tilt his head back.                 o 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. Do not confuse this with normal breathing. Look, listen, and feel for no more than 10 sec to determine if the victim is breathing normally. If you have any doubt whether breathing is normal, act as if it is not normal. 5 A If he is breathing normally:         Turn him into the recovery position (see below).         Send or go for help, or call for an ambulance.         Check for continued breathing. 5 B If he is not breathing normally:        Ask someone to call for an ambulance or, if you are on your own, do this yourself; you may need to           leave the victim.Start chest compression as follows:   o Kneel by the side of the victim. o Place the heel of one hand in the centre of the victim’s chest. o Place the heel of your other hand on top of the first hand. o 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 bony sternum (breastbone). o Position yourself vertically above the victim's chest and, with your arms straight, press down on the sternum 4 - 5 cm. o After each compression, release all the pressure on the chest without losing contact between your hands and the sternum. Repeat at a rate of about 100 times a minute (a little less than 2 compressions a second). o Compression and release should take an equal amount of time.

6 A 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 victim’s nose closed, using the index finger and thumb of your hand on his forehead.  Allow his mouth to open, but maintain chin lift.   Take a normal breath and place your lips around his mouth, making sure that you have a good seal.   Blow steadily into his mouth whilst watching for his chest to rise; take about one second to make his 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 chest to fall as air comes    out. Take another normal breath and blow into the victim’s mouth once more to give a total of two effective rescue     breaths 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 starts breathing normally; otherwise do not interrupt resuscitation.

If your rescue breaths do 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.   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 2 min to prevent fatigue. Ensure the minimum of delay during the changeover of rescuers.

6 B Chest-compression-only CPR.

If you are not able, 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 a minute. Stop to recheck the victim only if he starts breathing normally;otherwise do not interrupt resuscitation.

7 Continue resuscitation until

Qualified help arrives and takes over, The victim starts breathing normally, or You become exhausted.

Explanatory notes
Following successful treatment for choking, foreign material may nevertheless remain in the upper or lower respiratory tract and cause complications later.

Victims with a persistent cough, difficulty swallowing, or with the sensation of an object being still stuck in the throat should therefore be referred for a medical opinion. Abdominal thrusts can cause serious internal injuries and all victims receiving
abdominal thrusts should be examined for injury by a doctor.

Resuscitation of children and victims of drowning
Both ventilation and compression are important for victims of cardiac arrest when the oxygen stores become depleted – about 4-6 min after collapse from ventricular fibrillation (VF), and immediately after collapse for victims of asphyxial
arrest. Previous guidelines tried to take into account the difference in causation, and recommended that victims of identifiable asphyxia (drowning; trauma; intoxication) and children should receive 1 min of CPR before the lone rescuer
left the victim to get help. The majority of cases of sudden cardiac arrest out of hospital, however, occur in adults and are of cardiac origin due to VF. These additional recommendations, therefore, added to the complexity of the guidelines
whilst affecting only a minority of victims.

Also important is that 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, therefore, laypeople should be taught that the adult sequence may also be used for children who are not responsive and not breathing.

The following minor modifications to the adult sequence will, however, make it even more suitable for use in children

Give five initial rescue breaths before starting chest compressions (adult sequence of actions 5B).   If you are on your own perform CPR for approximately 1 min before going for help.   Compress the chest by approximately 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. The same       modifications of five initial breaths, and 1 min of CPR by the lone rescuer before getting help, may improve outcome     for victims of drowning. This modification should be taught only to those who have a specific duty of care to     potential drowning victims (e.g. lifeguards).     Drowning is easily identified. It can be difficult, on the other hand, for a layperson to determine whether        cardiorespiratory arrest has been caused by trauma or intoxication. These victims should, therefore, be managed     according to the standard protocol.