Clarification of first aid practices:
Position Statement re Control of Bleeding and CPR and
Rescue Breaths
ASPA Medical Advisory Committee – July 2013
Over the past couple of months some queries have been
raised with the Medical Advisory Committee as to current recommended practice
with regard to control of bleeding, CPR and rescue breaths and hands-only CPR.
The purpose of this document is to clarify ASPA’s position on these issues.
1. Control of Bleeding
ASPA continues to endorse the practices outlined in ARC Guideline 9.1.1 ((November 2008):
Principles for the Control of Bleeding for First Aiders. A copy of this
Guideline is being circulated with the latest issue of Asparations. These practices are also referred to in the current
ASPA Manual.
In summary, at first instance responders should seek
to identify the source of external bleeding and then attempt to control it via
firm direct pressure (e.g., using hands or a pad) and maintain this pressure.
If bleeding continues, apply another pad over the top of the first pad and a
tighter dressing over the wound. This should be combined with elevation and
immobilization of the affected part and restricting the movement of the
casualty.
If major bleeding continues then the pad(s) may be
removed in order to better identify the specific source of the bleeding and
then a further direct pressure pad and dressing applied.
Embedded objects should not be removed and padding and
pressure should be applied around/above/below the object.
A tourniquet may only be used as a last resort when
all other methods of controlling bleeding have failed. A wide bandage (at least
5cm) should be applied high above the bleeding point and should be tight enough
to stop both all circulation to the affected limb and stop the bleeding (and
the time noted). Once applied a tourniquet should not be removed until the
casualty is handed over to definitive care.
2. CPR, Rescue Breaths and Compression-Only CPR
ASPA continues to endorse the practices outlined in ARC Guideline 5 (December 2010): Breathing,
Guideline 8 (December 2010): Cardiopulmonary Resuscitation and Guideline 10.1 (March 2013): Basic Life
Support Training.
The Medical Advisory Committee has received reports that
suggest some training organizations in New South Wales are teaching that
compressions should not be paused for ventilations and that rescue breaths are
no longer an important part of CPR, compression-only CPR is acceptable for
trained rescuers and that these organizations prefer to use the American Heart
Association guidelines rather than the ARC Guidelines. These suggestions raise
a number of issues.
By way of background, in 2010 the American Heart
Association updated its own guidelines, and changed from an “A…B…C…” approach
to a “C…A…B…” approach in order to emphasise the importance of commencing chest
compressions as quickly as possible. However, these guidelines clearly state
both that rescue breathing remains an integral part of CPR for trained rescuers
and that hands-only CPR is better than no CPR in the case of an untrained lay
responder (such as someone receiving CPR instructions over the telephone from
an emergency dispatcher). The guidelines also refer (in numerous places) to
compressions being paused for ventilations and emphasise the importance of
minimizing interruptions to compressions and providing high-quality CPR. The
only circumstances in which compressions are not paused for ventilations is if
an advanced airway (for instance an endotracheal tube) is in situ.
An oropharyngeal (“Guedel”) airway is not an advanced
airway and should not be used routinely in CPR. Under the ASPA guidelines
(refer to the ASPA Manual), these
devices should only be used by qualified patrollers where airway patency (and
thus ventilation) is inadequate using standard airway management practices.
Aside from the matter of “ABC” versus “CAB”, the ARC
and AHA Guidelines are completely consistent in their recommendations regarding
CPR. As ASPA acknowledges the ARC to be the peak body for resuscitation
practices in Australia, ASPA continues to support the “A…B…C” approach
recommended by the ARC.
ARC Guideline 10.1
(March 2013): Basic Life Support Training
states:
“At a minimum, mouth to mouth
rescue breathing must be taught and assessed (in conjunction with the learning
objectives outlined (in this Guideline)),
in any training program.” The Guideline also recommends regular refreshing and
annual recertification of CPR skills.
ARC Guideline 8
(December 2010): Cardiopulmonary Resuscitation
states:
COMPRESSION VENTILATION RATIO
“Current consensus is that a universal compression-ventilation ratio
of 30:2 (30 compressions followed by two ventilations) is recommended for all
ages regardless of the numbers of rescuers present. Compressions must be
paused to allow for ventilations.”
ARC Guideline 5
(December 2010): Breathing states:
RESCUE BREATHING
“If the unconscious victim is
unresponsive and not breathing normally after the airway has been opened and
cleared, the rescuer must immediately commence chest compressions and then
rescue breathing. Give 30 compressions and then two breaths allowing about one
second for each inspiration following the Australian Resuscitation Council and
New Zealand Resuscitation Council Basic Life Support Flowchart (Guideline 8). …
Care should be taken not to over-inflate the chest.
Look for rise of the victim’s
chest during each inflation. If the chest does not rise, possible causes are:
• obstruction in the airway
(inadequate head tilt, chin lift, tongue or foreign material);
• insufficient air being
blown into the lungs;
• inadequate air seal around
mouth and or nose.
If the chest does not rise,
ensure correct head tilt, adequate air seal and ventilation.” Following
inflation of the lungs, rescuers should check for chest fall/exhalation.
In practical terms in order
to minimise interruption to compressions for ventilations, some simple
strategies may be of assistance. If the person doing the compressions counts
down the last few compressions, then the person delivering the ventilations can
be ready to deliver the first breath on the upstroke of the thirtieth
compression. If the person doing the compressions continues to rest their hands
gently on the chest during ventilations, this can serve a dual purpose of
monitoring rise and fall of the chest and being ready to restart compressions
as soon as exhalation from the second ventilation has occurred.
From the physiological
perspective, both circulation and oxygenation are required in order to give the
casualty the best possible chance of neurologically intact survival. This
requires both good quality CPR and effective ventilations.
As mentioned above, unless
there is an advanced airway in place, both the ARC and the AHA state that compressions
must be paused for ventilations in order to facilitate effective delivery of
air into the lungs. Forceful chest compression at the time of delivering a rescue
breathing ventilation is likely to result in mechanical obstruction and
ineffective ventilation, gas exchange and oxygenation. There is also a risk of
trauma to the casualty from raised airway pressure against an obstruction and
that air will preferentially travel down the oesophagus as a path of least
resistance into the stomach, increasing the risk of regurgitation and
aspiration.
Compression-only CPR
It is important to note that
this is only currently recommended for trained rescuers in situations where
standard CPR is not possible and as being better than no CPR for untrained lay
responders.
ARC Guideline 8
(December 2010): Cardiopulmonary Resuscitation
states:
CHEST COMPRESSIONS ONLY
“If rescuers are unwilling or
unable to do rescue breathing they should do chest compressions only. If chest
compressions only are given, they should be continuous at a rate of
approximately 100/min.”
There is an expectation that
ski patrollers (as trained rescuers) will always attempt rescue breathing in
addition to compressions unless there is a compelling reason as to why this is
not possible.
The ARC has placed some
explanatory information in the Frequently Answered Questions” section of its
website dealing with compression-only CPR. This is reproduced below by way of
information.
Australian Resuscitation Council - FAQ 9 – Compression-only CPR
The available published data
reveals conflicting evidence regarding benefit versus no benefit for
compression-only CPR. Strategies to improve the number of cardiac arrest
patients receiving bystander CPR should be encouraged but not to the
abandonment of conventional CPR.
Compression-only CPR should
be viewed as the first resuscitation step which should be followed as soon as
possible by rescue breathing and other basic life support interventions.
The Australian Resuscitation
Council continues to hold the view that any attempt at resuscitation is better
than no attempt, and if rescuers are unwilling or unable to do rescue breathing
they should do chest compressions only. If chest compressions only are given,
they should be continuous at a rate of approximately 100/min.
Australian Resuscitation Council – FAQs - The End of CPR as We Knew
it?
In a recent email [date
unknown ] from the USA, it was quoted: “In what may prove to be the biggest
shift in emergency care of cardiac arrest in 40 years, cities across the
country are leading a move away from the familiar practice of using
mouth-to-mouth resuscitation. In its place, the cities are recommending simple
chest compressions pushing down repeatedly on the victim’s chest – to mimic a
steady heartbeat.
The emergency medical
directors who are behind the shift say research in Seattle and
Richmond, Va, suggests it
will save many lives. The movement became a full-fledged national trend last
week at a meeting of emergency medical services (EMS) medical directors from 21
of the nation’s largest cities. Doctors from a dozen cities, including New
York, Los Angeles and Chicago, decided to make the switch. They join at least
seven other cities that are already advising 911callers to do chest
compressions without mouth-to-mouth “rescue breathing””.
This issue has received media
attention in the USA following a recent meeting of EMS medical directors. There
has also been a recent article in the Weekend Australian newspaper. It mainly results
from a study by Dr Hallstrom and published in Critical Care Medicine in 2000. In this study, callers to EMS
reporting a cardiac arrest and who did not know CPR, were asked if they wanted
to be instructed on how to do CPR. Those agreeing were randomised to receive instructions
over the phone to either do full CPR or just chest compressions. This is often referred
to ‘dispatcher assisted CPR’. The results of the study showed that the number
of survivors in each group to be similar (14.6% for compression only vs 10.4%
for full CPR)
It is important to note that the findings of this study refer only
to situations where no trained bystanders were performing CPR. It shows that
giving minimal telephone instructions (i.e. compressions only) seems to be as
effective in terms of survival as giving full CPR instructions over the phone.
However, this study does not compare the outcomes of untrained rescuers who
receive dispatcher assisted CPR with that of CPR being performed by trained
rescuers.
As such, inferring that mouth to mouth is not required when doing
CPR is not supported by any clinical evidence. Furthermore, it ignores other
causes of cardiac arrest such as drowning, and cardiac arrest in children,
where ventilation (ie mouth to mouth) is vital. Readers should be aware that
the recommendations of the EMS directors were that “compression only” CPR
advice should be given to callers receiving assistance from EMS dispatchers. It
did not recommend removing mouth to mouth ventilation from CPR training or
practice, as has been generally presented in the media.
Futher Reading:
Hallstrom AP. Dispatcher-assisted
"phone" cardiopulmonary resuscitation by chest compression alone or
with mouth-to-mouth ventilation. Critical
Care Medicine 2000;28(11 Suppl):N190-N192.
The Chair of the ASPA Medical
Advisory Committee has had the privilege (on a couple of occasions) of
participating in a meeting of the National Council of the Australian
Resuscitation Council and has observed at first hand the scientifically
rigorous, lengthy and complex procedure that is involved in creating and
updating the ARC Guidelines. This work is done by people who are internationally
recognised experts in resuscitation science and is based on the best available
evidence and expert opinion. The Guidelines are the “gold standard” and a
safety net for first aid providers. Emergency responders who choose to operate
outside the Guidelines are potentially placing both themselves and casualties
at risk. ASPA wishes to protect both patrollers and casualties and will
continue to look to the ARC for guidance on resuscitation practices.
For and on behalf of the ASPA
Medical Advisory Committee
July 2013
