|Danger||Is it safe to approach?|
Remove or manage any immediate danger. Do not ask for a definitive list of ‘dangerous circumstances’, stick to the simple to understand principles. If it is safe to approach, proceed quickly, if there is manageable danger, manage the danger, and if it is too dangerous or complex to proceed, dial 999 in the first instance.
|Response||Is victim responsive or unresponsive?|
Gently try to rouse the victim using ‘shake and shout’. Try to stimulate a response by gently shaking the victim by the shoulders and asking loudly “are you alright?”.
You do not need to teach to shout into each of the victim’s ears in turn ‘in case they are deaf in one ear’. Someone who is unresponsive is considered ‘unconscious’ and needs immediate further assessment and professional help.
If the victim responds, leave them in the position you found them and try to ascertain whether they want/need help and summon accordingly. Re-assess the victim frequently.
|Alert others||Alert others to your situation to expedite a response (this does not have to be done at a specific point).|
Shout for help and alert others to the emergency. If on your own, do not phone 999 until you know whether the victim is breathing or not. If there are multiple bystanders, they can call 999 (see below) and get a defibrillator to your aid – the sooner the better. Be aware that some rural areas may have procedures for alerting local volunteers and this should be discussed in the context of summoning additional help whilst ensuring that the 999 call is made without delay.
|Airway||Use head tilt and chin lift to manually open airway.|
Place a hand on the victim’s forehead and then lift the bony part of the point of the chin. When you know there is neck trauma, you may assess for breathing first, but if breathing is absent, an airway opening manoeuvre is required and takes priority over cervical spine control.
|Breathing||Look, listen and feel for normal breathing for no more than 10 seconds.|
Maintain head tilt and chin lift and:
Look at the victim’s chest to ascertain whether they are breathing normally. Look for regular rise and fall of the chest associated with ‘normal breathing’.
Listen for noises of breathing near to the victim’s airway.
Feel for expired air with your cheek next to the victim’s mouth. The ‘feel’ does not refer to placing a hand on the chest as this necessitates removal of a hand that is keeping the airway open.Discuss gasping or agonal breathing and apparent seizures and that these should not be confused with ‘normal breathing’. Wherever possible, learners should be shown a video of agonal gasps to aid recognition (widely available on the internet).
Assessment of breathing should take long enough to make an accurate assessment but should not delay commencement of CPR. Assessment should take no more than 10 seconds.If breathing normally:
Place them in the recovery position.
Summon additional help. Dial 999 if necessary.If NOT breathing normally:
Dial 999, start CPR.
|Dial 999||Dial 999, send someone to find and bring an AED.|
Cover activation of local emergency team, first responders, the National Defibrillator Network (NDN), GoodSAM, AEDs or national emergency services. Information required: Location and victim not breathing, starting CPR. Where possible this should be done without delay in starting chest compressions. If alone, where possible, use mobile phone on speakerphone. When there are others present, ensure they dial 999 and confirm to you that they have done so whilst you perform chest compressions.Getting an AED is the next practical priority once CPR has been started.
|Circulation/ CPR||Start chest compressions.|
Ensure correct hand position (middle of lower half of sternum). Do not teach ‘measuring techniques,’ just identify the centre of the chest. Do this with good practical demonstration.
Compression depth 5-6cm. This is difficult to teach and assess without a manikin that gives feedback. Emphasise that quality of chest compressions is directly related to survival.
Compression rate 100-120 per minute. Ensure full recoil of chest between compressions. Spend as much time on compression as recoil, keep it smooth. Rescuer’s arms should be straight at the elbow with shoulders vertically above the heels of the hands. The rescuer’s weight should be through the heel of the hand directly onto the bony sternum. The best position for performing chest compressions is kneeling beside the victim. It does not matter which side you do it from.DO NOT interrupt CPR (chest compressions) unless:
- a healthcare professional tells you to stop,
- the casualty is definitely waking,
- or you become exhausted
Discuss rescuer fatigue and importance of maintaining quality of chest compressions and chest compression fraction. This is the percentage of time in which chest compressions are done by rescuers during a cardiac arrest. In a real-world cardiac arrest, CPR is often interrupted or delayed by things such as rescue breaths, pulse checks and heart rhythm analysis. Unnecessary interruptions to CPR (e.g. randomly checking for breathing when there are no obvious signs of life) reduces survival rates.
If there is more than one rescuer, change the chest compression provider every two minutes ensuring that delays in chest compressions are minimal.
If combining with ventilation, perform 30 compressions to every 2 ventilations. If unable, unwilling or unsure how to give artificial ventilations, just perform continuous chest compressions until additional help is available and ventilation established.
|Rescue breaths/ ventilations||Give 2 rescue breaths/ventilations.|
Having performed at least 30 chest compressions and provided that it is safe to do so, and the rescuer is trained, willing and able to perform mouth-to-mouth, 2 breaths should be given, immediately followed by 30 compressions. Continue delivering this ratio of 30 compressions to 2 ventilations. Delays to chest compressions should always be minimised and no more than 10 seconds should be taken to give 2 ventilations.
Demonstrate and recommend correct use of barrier devices and pocket masks. Where appropriate and with more highly trained and skilled learners this may include correct use of bag-mask ventilation (2-person technique) with supplemental oxygen. Assembling these devices takes too long for a single rescuer to achieve, so if unwilling to give direct mouth-to-mouth, consider delaying use of additional ventilation devices until more rescuers arrive.
Continue CPR until help and/or AED arrives.
|For paediatric resuscitation, modifiers to adult guidelines may be taught. These modifiers include: depth of chest compression appropriate to body size (third of the depth of the chest), importance of ventilating, if possible, and that applying the adult guidelines to a child is acceptable.|
|Turn on AED and follow prompts||Further emphasise need to minimise interruptions to chest compressions until help arrives or AED tells you to pause.|
Do not stop chest compressions whilst waiting for equipment (AED) to be brought and applied. If alone and unless an AED is within easy reach, do not leave the victim in order to retrieve an AED as stopping chest compressions will reduce the chance of survival. Asking other people to find and bring the nearest AED is the best course of action and this process can be informed by the 999 call handler who will have access to the National Defibrillator Network database.
Cover types of AED and ways of accessing them. Public-access defibrillators, locally available resources (e.g. appointed first aiders, common AED locations – supermarkets, gyms, transport hubs etc.), role of ambulance control/despatcher and ‘AED Location Apps’ as well as initiatives such as ‘GoodSAM’.
Locate ‘ON’ button and push firmly. Follow voice prompts. Listen carefully and minimise interruptions to CPR whilst attaching AED pads. The most expedient way to do this is to ask a helper (trained or untrained) to give continuous chest compressions while the person who is most familiar with the AED applies the AED pads.
Chest needs to be bare, dry and relatively hair free. Shave the chest only if the hair is excessive, and even then, spend as little time as possible on this. Do not delay defibrillation if a razor is not immediately available.
Pads should be applied one at a time immediately after removing backing from self-adhesive covering.
Position pads below right clavicle and in the left axilla.
Stop CPR when AED tells you to, to allow it to analyse heart rhythm.
If shock advised, deliver shock without delay ensuring other rescuers are not touching the victim, then restart CPR.
If no shock advised, resume CPR immediately unless the victim is definitely waking up, moving, opening eyes AND breathing normally.
Continue to follow prompts, advise that the AED works on 2-minute cycles of CPR and analysis.
Discuss how to communicate with the EMS.
Discuss paediatric mode and modifiers.