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BSAC
Basic Life Support Guidlines
General
Points
The following guidance has been prepared
by the Safety and Rescue Skills Advisor and endorsed by the National
Diving Committee to update our guidance and procedures in light of
current advice and guidance available from all relevant sources.
Background
to changes
Changes
to BSAC Guidance and Training
Terminology
Guideline
change
The
major changes are
Basic
Life Support Sequence
In-water
Artificial Ventilation (AV) now Rescue Breaths (RB):
Diving
casualties
Principles
of rescue
In-water
Rescue Breaths (RB)
Changes
to In-water Rescue
Breaths Guidance
Background
to changes
The techniques for life support and resuscitation taught by the BSAC
currently are based on an international collaboration between experts
in resuscitation medicine from the world’s major
resuscitation organisations and are therefore consistent not only with
other agencies providing training to lay rescuers, but also with the
techniques used by doctors, nurses and others working in medical
services around the world. These techniques are all based on the best
evidence as to what is most effective.
As knowledge advances a regular review of this evidence is needed and
such a review took place in 2005 leading to the publication of the 2005
International Consensus on Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care Science with Treatment Recommendations (CoSTR, Ref
1). This formed the scientific basis for the European Resuscitation
Council (ERC) Guidelines for Resuscitation (2005) (Ref 2) and the
Resuscitation Council (UK) Guidelines 2005 (Ref 3).
The BSAC has considered the revised guidelines and this document
represents the BSAC recommended technique for basic life support. The
training materials for the Diver Training Programme and Skill
Development Courses will be revised to incorporate these changes. It
will take time for courses and training materials to be updated and for
changes in practice to be disseminated. During this period there will
be some variation in practice between individuals. There is no evidence
that the “old” techniques based on guidance
published in 2000, were dangerous or ineffective, however this new
approach is recommended and is based on the best available evidence as
to what is most effective. Changes in practice such as this emphasise
the importance of always keeping these rescue skills current and in
practice by regular up-to-date training.
Changes
to BSAC Guidance and Training
Terminology
The revision of the Resuscitation Guidance for the BSAC is an
opportunity to bring nomenclature in line with that used by other
rescue agencies and resuscitation training agencies.
The term “Resuscitation” refers to a wide variety
of techniques to promote recovery in casualties who have suffered
cardiac and/or respiratory arrest. These techniques encompass some
which are appropriate for lay rescuers with minimal and often no
equipment, through rescuers with progressively more training and
facilities, to those methods only available in hospitals.
The technique first introduced in the Diver Training Programme at ST2
and referred to as “Resuscitation” should be
referred to as “Basic Life Support”.
The rationale for this is:
•
This is consistent with other training agencies which use this term for
this technique which requires no equipment
•
The term “Basic Life Support” emphasises the
purpose of the technique (i.e. to maintain the viability of the
casualty)
•
It reduces the expectation that this technique alone will promote full
recovery
•
It therefore emphasises the need to obtain help urgently
•
It will potentially reduce the likelihood of self-recrimination in the
rescuer in the event of an unsuccessful rescue attempt
•
It is consistent with the principle of progressive training with the
introduction of pocket mask, oxygen enrichment and airway adjuncts
later in training in the rescue SDCs
The technique generally referred to as
“Artificial Ventilation” (“AV”)
throughout the DTP and SDCs should be renamed “Rescue
Breathing”.
•
This again promotes consistency across agencies
•
It also emphasises a distinction between other types of
artificial ventilation taught currently in the Rescue First Aid SDC
Thus “Basic Life Support” encompasses rescue
breathing and cardiac compressions only.
Guideline change
The main aim of the guidance change has been to reduce the possibility
that cardiac compressions are interrupted during basic life support. It
has been recognised that such interruptions are common and are
associated with reduced chances of survival for the casualty.
The
major changes are
1) Cardiac arrest is diagnosed if a casualty is unresponsive and not
breathing normally.
2) Rescuers should place their hands in the centre of the chest, rather
than spend more time positioning their hands using other methods.
3) Each rescue breath is given over 1 sec rather than 2 sec.
4) Use a ratio of compressions to Rescue Breaths of 30:2 for all
casualties.
5) Once the casualty is on land, on diagnosing cardiac arrest,
•
summon help, leaving the casualty if necessary
•
give 30 compressions immediately
•
follow this by 2 rescue breaths (Unless there are OBVIOUS
signs of circulation)
•
give 30 compressions followed by 2 rescue breaths
•
continue compressions and ventilation at 30:2 ratio.
Basic
Life Support Sequence
In diving situations it is very unlikely that a lone rescuer will
initiate these actions on land or in a boat. The most likely scenario
is that Life support attempts will have been initiated in the water by
a lone rescuer, and once the casualty is out of the water other members
of the diving group will be available for help. Once the casualty is on
land or in a boat the following sequence should be followed.
1 Make sure you, the casualty and any other divers or bystanders are
safe.
2 Check the casualty for a response
•
gently shake his shoulders and ask loudly:
‘‘Are you all right?’’
3a If he responds
•
leave him in the position in which you found him provided
there is no further danger
•
try to find out what is wrong with him and get help if needed
•
reassess him regularly
3b If he does not respond
•
shout for help
•
turn the casualty onto his back and then open the airway by
placing your hand on his forehead and gently tilting his head back,
keeping your thumb and index finger free to close his nose if rescue
breathing is required
•
with your fingertips under the point of the
casualty’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 casualty’s mouth for breath sounds.
•
Feel for air on your cheek.
•
In the first few minutes after cardiac arrest, a casualty
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 seconds to determine whether the casualty is breathing
normally. If you have any doubt whether breathing is normal, act as if
it is not normal.
5a If he is breathing normally
•
turn him into the recovery position
•
send or go for help/call for an ambulance
•
check for continued breathing
5b If he is not breathing normally
•
send someone for help or, if you are on your own, leave the
casualty and do this yourself; return and start chest compression as
follows:
o
kneel by the side of the casualty
o
place the heel of one hand in the centre of the casualty’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 casualty’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 casualty’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
o
repeat at a rate of about 100/min (a little less than 2 compressions
per second)
o
compression and release should take equal amounts of time
6 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 nose closed, using the index
finger and thumb of your hand on the forehead.
•
Allow the mouth to open, but maintain chin lift.
•
Take a normal breath and place your lips around his the
mouth, making sure that you have a good seal.
•
Blow steadily into the mouth while watching for the chest to
rise, taking about 1 second as in normal breathing; this is an
effective rescue breath.
•
Maintaining head tilt and chin lift, take your mouth away
from the casualty and watch for the chest to fall as air passes out
•
Take another normal breath and blow into the
casualty’s mouth once more, to achieve 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 casualty only if he starts breathing
normally; otherwise do not interrupt resuscitation.
If your initial rescue breath does not make the chest rise as in normal
breathing, then before
your next attempt:
•
check the casualty’s mouth and remove any
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
every 1—2 min to prevent fatigue. Ensure the minimum of delay
during the changeover of rescuers.
References
1. International Liaison Committee on Resuscitation. 2005 International
Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular
Care Science with Treatment Recommendations. Resuscitation 2005; 67:
157 – 341.
2. European Resuscitation Council. European Resuscitation Council
Guidelines for Resuscitation 2005. Resuscitation 2005; 67(Suppl. 1): S1
– S190.
3. Resuscitation Council (UK). Resuscitation Guidelines 2005. ISBN
1-903812-10-0. (available at www.resus.org.uk)
©BSAC 2006 Basic Life
Support Guidelines 2006
In-water
Artificial Ventilation (AV) now Rescue Breaths (RB):
Clarification
of technique
The early initiation of Rescue Breaths
(RB) (previously Artificial Ventilation (AV)) is an essential treatment
for a drowning casualty. Current guidance for the treatment of drowning
recommends that this should be started in-water if the rescuer is
trained to do so (1). The BSAC teaches such a technique. This following
text will
•
describe the technique for effective in-water Rescue Breaths (RB)
•
incorporate the recently published guidance on this
•
recap BSAC guidance as to the rate of in-water AV issued in 2004
Diving
casualties
A non-breathing diving
casualty may have suffered many different types of injury to cause the
absence of breathing, however because the casualty has suffered these
while submerged or immersed in water, drowning must be considered a
primary cause or major contributing factor to the casualty’s
condition and the casualty should be treated for drowning.
Principles of rescue
The casualty must be removed from the water by the fastest and safest
means possible. The rescuers should be aware of their personal safety
and minimise danger to themselves and the casualty at all times.
Variations in technique may be necessary depending upon the physical
build and the equipment of both the casualty and rescuer. Therefore the
principles of the technique will be emphasised rather than dogmatically
require a standard method.
In-water
Rescue Breaths (RB)
•
The rescuers should be aware of their personal safety and minimise
danger to themselves and the casualty at all times.
•
The casualty must be removed from the water by the fastest and safest
means possible.
1. The rescuer must make a firm hold on
the casualty and maintain this throughout the rescue.
•
Suitable hold includes on the top of the casualty’s cylinder,
or BC strap
•
Ideally this hold will allow the rescuer to “roll”
the casualty towards them in the event of Rescue Breaths (RB) being
needed
2. The rescuer should make the casualty
and themselves buoyant at the surface.
•
Ensure adequate inflation of buoyancy device to float casualty safely
with airway clear of the water in the event of spontaneous breathing
returning
•
Avoid overinflation preventing adequate neck extension
•
Consider the dropping of weight belts/pouches to ensure both maintain
position on the surface
3. Open the casualty’s airway by
applying gentle neck extension
•
The hand not being used to hold the casualty should be applied to the
casualty’s chin
•
Avoid applying pressure over the centre of the neck (trachea)
•
The forearm should be close into the side of the casualties neck (Fig
1) so that the neck can be extended by using the forearm as a
“lever”
•
The casualty’s head should be tilted backwards as if they
started out looking straight ahead and then directly overhead, ie the
head should not tilt from side to side
•
The purpose of neck extension is to prevent the tongue falling back in
the throat. In training, a test of the adequacy of the neck extension
is that a student simulating the role of “casualty”
will have difficulty swallowing if the neck is extended
•
During training divers simulating the role of a casualty should be
briefed to relax and rescuers briefed not to forcefully gain the neck
extension to avoid the risk of injury.
4. If there is no spontaneous breathing on
opening the airway in this way give Rescue Breaths (RB) for
approximately 1 minute (10 Rescue Breaths)
•
The fingers of the hand applied to the casualty’s chin should
make an airtight seal over the mouth
• This can be achieved in a number of ways e.g.
o
Direct pressure across the lips
o
Pressing the lips upwards towards the nose
• In training, a test of the
adequacy of this seal is that a student simulating the role of
“casualty” will have difficulty blowing out through
the mouth
• The rescuer should “roll” the casualty
towards them whilst still maintaining the position in Fig 1
• The rescuer makes a seal with his mouth over the
casualty’s nose and applies a rescue breath
• Ventilations should be given at a minimum rate of two
breaths every 15 seconds
o
Each breath should take approximately 5 seconds allowing 1 second for
inflation and the natural deflation of the chest for approximately 4
seconds
o
Careful monitoring for effectiveness and finding a natural rate is more
appropriate than slavish adherence to nominal rates
Changes to In-water Rescue
Breaths Guidance
In February 2006 the National Diving Committee approved amendments I
had proposed to our Basic Life Support Guidance in line with the
recommendations of the Resuscitation Council. These changes are
summarised in the document ‘BSAC Basic Life Support
Guidelines 2006’ and Instructors, Branch Officers and all
divers should make themselves familiar with them. However, one of these
changes significantly implicates on the Guidance above and represents a
change in our in-water Rescue Breathing (RB) (formerly AV) advice when
it comes to dekitting and removal of a casualty from the water. This is
summarised in the box below.
1
minute rescue breathing (10 Rescue Breaths)
If
no spontaneous breathing returns…
Tow
with rescue breathing at 2 breaths/ 15 seconds
When
in standing depth, or at boat prior to landing…
1 further minute rescue breathing
(10 Rescue Breaths)
Then dekit and land as quickly as
possible WITHOUT further rescue
breathing
Begin
basic life support according to the 2005 algorithm i.e. 30
cardiac compressions initially then two rescue breaths
Andy Procter, Safety & Rescue Skills Advisor - February 2006
Reference
(1) Soar J et al (2005) European Resuscitation Council Guidelines for
Resuscitation 2005. Section 7. Cardiac arrest in special circumstances.
Resuscitation 67S1, S135-S170
©BSAC 2006 Basic Life
Support Guidelines 2006
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