Adult resuscitation in primary care
General Practitioner, Isle of South Uist, Western Isles, UK
E-mail: johnbuckmaster{at}doctors.org.uk
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Abstract |
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 TOP Abstract The GP curriculum and...Basic adult life supportUse of automated external...Advanced adult life supportDuration of resuscitationRecording resuscitation attemptsDo not attempt to...References |
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As a doctor, at any stage of your training, you may in the course of your work, and sometimes outside it, be called upon to administer resuscitation to either a patient or another person. All general practitioner's (GP) practices should have a defibrillator, and defibrillators are often available in public places such as stations and supermarkets. The Quality and Outcomes Framework rewards practices for regularly updating cardiopulmonary resuscitation (CPR) skills of practice clinical and non-clinical staff (education indicators 1 and 5). In addition, all members of the public should be encouraged to consider taking the basic training as the earlier cardiopulmonary resuscitation is initiated after a collapse, the more likely it is to succeed.
Acutely ill people of all ages present unpredictably, interrupting work and routines and requiring an urgent response. They may be seen in familiar contexts such as the surgery, on home visits and in out-of-hours centres; the GP may be asked to give assistance in unfamiliar and unsupported surroundings such as at the roadside. Royal College of General Practitioners Curriculum Statement 7: Care of Acutely Ill People states that GPs should:
Acute care competencies from Foundation Years 1 and 2
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Basic adult life support |
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TOPAbstractThe GP curriculum and...Basic adult life supportUse of automated external...Advanced adult life supportDuration of resuscitationRecording resuscitation attemptsDo not attempt to...References |
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This is carried out to maintain the circulation and oxygen intake of the patient. It is a holding operation in order to sustain life until help arrives (Fig. 1). It should be started as soon as cardiopulmonary arrest is detected—the outcome is less good the longer the delay. Techniques described here are best learned at a practical class or during your time as a hospital doctor. There is no substitute for doing it yourself either on a patient as a hospital doctor or on a mannequin at a training session. Follow the following steps:
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- 1) Danger: In any situation requiring you to carry out basic adult life support, remember to ensure both your own safety and that of the patient. The safety of bystanders is also of importance.
- 2) Response: Check for any response (AVPU):
- Is the patient Alert? Yes/No
- Does he respond to Vocal stimuli? Yes/No
- Does he respond to a Painful stimulus (such as pinching the lower part of the nasal septum)? Yes/No
- Is the patient Unconscious? Yes/No
- 2) Response: Check for any response (AVPU):
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If the patient responds by answering or moving, do not move the patient unless he or she is in danger. Get help urgently and reassess regularly.
If the patient does not respond, shout for help. Turn the patient onto his or her back and, if possible, move the patient onto a firm surface if not already on one.
| If spinal cord injury is suspected (for example, if the victim has sustained a fall, been struck on the head or neck or has been rescued after diving into shallow water), take particular care during handling and resuscitation to maintain alignment of the head, neck and chest in the neutral position. Try to avoid head tilt if trauma to the neck is suspected. A spinal board and/or cervical collar should be used if available.
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- 3) Airway: open the airway by placing one hand on the patient's forehead and tilting his or her head back. Using the fingertips under the point of the patient's chin, lift the chin to open the airway.
- 4) Breathing: With the airway open, look, listen and feel for breathing for up to 10 seconds. If you put your ear to the victim's mouth and look down toward the chest, you can hear any sounds, feel any breaths on your cheek and see any rise and fall of the chest wall.
- 4) Breathing: With the airway open, look, listen and feel for breathing for up to 10 seconds. If you put your ear to the victim's mouth and look down toward the chest, you can hear any sounds, feel any breaths on your cheek and see any rise and fall of the chest wall.
If the patient is breathing normally, turn the patient into the recovery position, make sure help is coming and reassess regularly for continued breathing.
If the patient is not breathing or only making occasional gasps or weak attempts at breathing, get help and then start chest compressions. 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. If you have any doubt whether breathing is normal, then act as if the patient is not breathing.
- 5) Circulation: If the patient is not breathing, then start chest compressions.
- Kneel by the side of the victim and place the heel of one hand in the centre of the victim's chest. Place the heel of your other hand on top of the first hand. 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.
- Position yourself vertically above the victim's chest and, with arms straight, press down on the sternum 4–5 cm.
- After each compression, release all the pressure on the chest without losing contact between your hands and the sternum. Compression and release should take an equal amount of time.
- Repeat at a rate of about 100 compressions per minute.
- 6) Combine chest compressions with rescue breaths: After 30 chest 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 already on his or her forehead. Allow the victim's mouth to open, but maintain chin lift.
- Kneel by the side of the victim and place the heel of one hand in the centre of the victim's chest. Place the heel of your other hand on top of the first hand. 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.
Give a rescue breath. Take a normal breath and place your lips around the victim's mouth (mouth-to-nose technique is an alternative) making sure that you have a good seal. Blow steadily into the victim's mouth for about a second while watching for the chest to rise.
Maintaining head tilt and chin lift, take your mouth away from the victim and watch for the chest to fall as air comes out. Take another normal breath and blow into the victim's mouth again 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 chest compressions and rescue breaths in a ratio of 30 : 2.
Stop to recheck the victim, if the patient makes a movement or takes a spontaneous breath. Otherwise, resuscitation should not be interrupted.
If rescue breaths do not make the chest rise, 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 in each 30 : 2 cycle, before returning to chest compressions.
When to go for assistance
It is vital for rescuers to get assistance as quickly as possible. If you are the only rescuer, go for assistance before starting CPR. If more than one rescuer is available, one should start resuscitation while another goes for assistance. Another should takeover CPR every 2 minutes to prevent fatigue. Ensure the minimum of delay during changeover of rescuers.
Chest compression-only CPR
If you are unable or unwilling to give rescue breaths, give continuous chest compressions only at a rate of 100 compressions per minute.
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Use of automated external defibrillators in adults |
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TOPAbstractThe GP curriculum and...Basic adult life supportUse of automated external...Advanced adult life supportDuration of resuscitationRecording resuscitation attemptsDo not attempt to...References |
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Automated external defibrillators (AEDs) should be programmed to deliver a single shock followed by a pause of 2 minutes for the immediate resumption of CPR. If a patient arrests, start CPR according to the guidelines for basic life support. As soon as the AED arrives (Fig. 2):
- Switch on the AED and attach the electrode pads. If more than one rescuer is present, continue CPR while this is done. Some AEDs automatically switch on when the AED lid is opened.
- Place one AED pad to the right of the sternum, below the clavicle
- Place the other pad in the mid-axillary line with its long axis vertical
- Follow the voice and/or visual prompts. Ensure nobody touches the victim while the AED is analysing the rhythm.
- If a shock is indicated, ensure that nobody is touching the victim. Push the shock button as directed. Fully automatic AEDs deliver the shock automatically. Immediately resume CPR and continue to follow the prompts.
- If no shock is indicated, immediately resume CPR and continue to follow the prompts
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Advanced adult life support |
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TOPAbstractThe GP curriculum and...Basic adult life supportUse of automated external...Advanced adult life supportDuration of resuscitationRecording resuscitation attemptsDo not attempt to...References |
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There are three main stages for ALS (Fig. 3):
- 1) Revive the patient using basic life support. Basic life support should be started if there is any delay in obtaining a defibrillator, but must not delay shock delivery. In adults, CPR should be performed at a ratio of 30 chest compressions to 2 rescue breaths. If the airway has been secured and there is more than one rescuer, chest compression should be continued without pausing during ventilation.
- 2) Restore spontaneous cardiac output using a manual or automatic defibrillator
- 3) Review possible causes for cardiac arrest and take further action as needed
- 2) Restore spontaneous cardiac output using a manual or automatic defibrillator
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Precordial thump
It is worth performing a precordial thump if the arrest is witnessed and a defibrillator is not to hand. It may dislodge a pulmonary embolus or ‘jerk’ the heart back into sinus rhythm. Use the ulnar edge of a tightly clenched fist and deliver a sharp impact to the lower half of the sternum from a height of about 20 cm and then immediately retract the fist.
Ventricular fibrillation or ventricular tachycardia arrests
In an arrest situation, if the electrocardiogram (ECG) monitor shows ventricular fibrillation (VF) or ventricular tachycardia (VT), attempt defibrillation. Give one shock (150–200 J biphasic or 360 J monophasic) as soon as possible. Immediately resume chest compressions (30 : 2) without reassessing rhythm or feeling for the pulse.
Continue CPR for 2 minutes, then pause briefly to check the monitor. If VF or VT persists, give a second shock (150–360 J biphasic or 360 J monophasic). Continue CPR for a further 2 minutes, then pause briefly to check the monitor again.
If VF or VT persists, give adrenaline (epinephrine) 1 mg intravenously (IV) or intraosseously if IV access cannot be attained, followed immediately by a third shock (150–360 J biphasic or 360 J monophasic). Resume CPR immediately and continue for 2 minutes, then pause briefly to check the monitor again.
If VF or VT persists, give amiodarone 300 mg IV (lidocaine 1 mg/kg is an alternative if no amiodarone is available) followed immediately by a fourth shock (150–360 J biphasic or 360 J monophasic). Resume CPR immediately and continue for 2 minutes.
Thereafter, give adrenaline (epinephrine) 1 mg IV immediately before alternate shocks (i.e. approximately every 3–5 minutes). Give a further shock after each 2-minute period of CPR and after confirming that VF or VT persists.
Non-VT/VF arrests
Start CPR and, without stopping the CPR, check that the ECG leads are attached correctly. Give adrenaline (epinephrine) 1 mg as soon as IV access is achieved. If there is asystole or pulseless electrical activity with a rate of less than 60 beats per minute, give atropine 3 mg IV once only. Recheck the rhythm after each 2-minute block of CPR and proceed accordingly. Give adrenaline (epinephrine) 1 mg IV every 3–5 minutes (alternate loops).
Fine VF
Fine VF which is difficult to distinguish from asystole is unlikely to be shocked successfully into a perfusing rhythm. Continuing good quality CPR may improve the amplitude and frequency of the VF and improve the chance of successful defibrillation to a perfusing rhythm.
Organized electrical activity
If organized electrical activity is seen during the brief pause in compressions, check for a pulse. If a pulse is present, start post-resuscitation care. If there is no pulse, then continue CPR and follow the non-shockable algorithm.
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Duration of resuscitation |
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TOPAbstractThe GP curriculum and...Basic adult life supportUse of automated external...Advanced adult life supportDuration of resuscitationRecording resuscitation attemptsDo not attempt to...References |
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Continue resuscitation until qualified help arrives and takes over, the victim starts breathing normally and/or you become exhausted. If the patient starts to breath spontaneously, then turn the patient into the recovery position (Box 1 and Fig. 4) and monitor frequently.
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Box 1. Putting a patient in the recovery position (letters correspond to those in Fig. 4)
Note: Monitor the peripheral circulation of the lower arm. If the patient has to be kept in the recovery position for greater than 30 minutes, turn the patient onto the opposite side.
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Recording resuscitation attempts |
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TOPAbstractThe GP curriculum and...Basic adult life supportUse of automated external...Advanced adult life supportDuration of resuscitationRecording resuscitation attemptsDo not attempt to...References |
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Accurate records of all resuscitation attempts and electronic data stored by most AEDs during a resuscitation attempt should be kept for audit, training and medico-legal reasons. The responsibility for this rests with the most senior member of the practice team involved. Process and outcome of all resuscitation attempts should be audited—at practice and Primary Care Organization level—to allow deficiencies to be addressed and examples of good practice to be shared.
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Do not attempt to resuscitate (DNAR) decisions |
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TOPAbstractThe GP curriculum and...Basic adult life supportUse of automated external...Advanced adult life supportDuration of resuscitationRecording resuscitation attemptsDo not attempt to...References |
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If no explicit decision has been made in advance about CPR and the wishes of the patient are unknown, there should be a presumption that health professionals will make all reasonable efforts to attempt to revive the patient in the event of cardiac or respiratory arrest. In some situations, attempting resuscitation of a patient might be inappropriate. This should be discussed in advance by all health professionals likely to be involved with the care of the patient and, where possible, the patient or patient's representative. Any decision about whether or not to attempt CPR must be readily accessible to all health professionals who may need to know it. The patient's record should contain clear documentation of the decision and how it was made, the date of decision and the reasons for it and the name and position of the person responsible for making the decision. All decisions not to attempt resuscitation should be reviewed regularly in light of the patient's condition.
Key points
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References |
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TOPAbstractThe GP curriculum and...Basic adult life supportUse of automated external...Advanced adult life supportDuration of resuscitationRecording resuscitation attemptsDo not attempt to...References |
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RCGP. GP Curriculum Statement 7: Care of acutely ill people. Accessed via www.rcgp-curriculum.org.uk/PDF/curr_7_Acutely_ill_people.pdf [date last accessed 31.03.2008].
Resuscitation Council (UK). Resuscitation guidelines (2005).
Adult basic life support. Accessed via www.resus.org.uk/pages/bls.pdf [date last accessed 31.03.2008].
Adult advanced life support. Accessed via www.resus.org.uk/pages/als.pdf [date last accessed 31.03.2008].
Resuscitation Council (UK) and the Royal College of Nursing Decisions relating to cardiopulmonary resuscitation. (2007) Accessed via www.resus.org.uk/pages/dnar.pdf [date last accessed 31.03.2008].
Simon C, Everitt H, Kendrick T. Oxford Handbook of General Practice (2005) 2nd edition. Oxford: Oxford University Press. ISBN: 019856581X.
Simon C, O’Reilly K, Proctor R, Buckmaster J. Emergencies in Primary Care (2007) Oxford: Oxford University Press. ISBN: 0198570686.
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