Resuscitation

[majo]

All,

For your information.

the new 2005 resuscitation protocols are out today. I know you all will follow your training till you recieve new guidelines from your agencies etc but thought you would all like to have the information.

The new protocols are written for the benefit of lay people and sudden cardiac arrest and not for drowning situations.

There is a modification to the protocols for people involved with drowning ( it specifies lifeguards, such divers also fit that)

For Adult the BLS is as follows:
"The following changes in the BLS guidelines have been made to reflect the greater importance placed on chest compression, and to attempt to reduce the number and duration of pauses:
1) Make a diagnosis of cardiac arrest if a victim is unresponsive and not breathing normally.
2) Teach rescuers to place their hands in the centre of the chest, rather than to spend more time using the ‘rib margin’ method.
3) Give each rescue breath over 1 sec rather than 2 sec.
4) Use a ratio of compressions to ventilations of 30:2 for all adult victims of sudden cardiac arrest. Use this same ratio for children when attended by a lay rescuer.
5) For an adult victim, omit the initial 2 rescue breaths and give 30 compressions immediately after cardiac arrest is established."
More information can be found on the UK Resuscitation Council, look at http://www.resus.org.uk/pages/guide.htm

http://www.resus.org.uk/pages/bls.pdf this has the pdf of the new protocol and the section on drowning.

I have emailed BSAC for their Views and I am awaiting information from the RLSS UK (i'm a lifeguard trainer) and the Red Cross (trainer again).

When I have more information I will post it, if anyone wants to discuss it further please do so. It has implications for divers due to the general public not being trained in a method that is specificaly directed for us in a drowning situation.

Regards,

Mark

[Andy Botten]

Near the end of the document are changes for drowning

Five Rescue Breaths followed by one minute of CPR before going for help

[Sean Gribben]

Hi Majo & Andy.
As leader of NDC Diver Training Group this falls under my remit.
Andy Procter, Chief of Rescue Skills, is looking into the advice given and will, when his time permits, issue guidance to our membership.
Thankyou also for the links Majo, most useful.

Sean

[Andy]

Thanks for putting up the links to the Resuscitation Council (UK) sites Majo - I was about to do that myself after I saw the documents there today. I will be writing some guidance for our members soon.
Andy Procter - Safety and Rescue

[David Walker]

Just wondering, what is BSAC's official guidance on two-person CPR? It changed a while ago for most other resus / lifesaving organisations as far as I can tell to say that all "amateur" (ie not a medical professional) CPR should be one-person - if you've got two people then they should swap over both roles when one gets tired - but that they shouldn't any longer have one doing compressions, the other doing AV. Of course this isn't particularly practical if we're doing oxygen-enriched AV or whatever (need to hold the mask on, etc).

Could BSAC look at this as well and let us know if we should be changing the way we teach it, and whats the best way for diving?

Cheers

David

[Gordon]

As a mildly interesting aside,

I did a first aid course with a paramedic about 3months ago and was told that 15:2 is the ideal ratio (it was at the time ...) but that he would rather have someone doing say 20:4 efficiently than someone sticking to 15:2 but acheiving naff all.

Is it really necessary to continually update ratios and speeds? Surely making sure people are doing it right and not confusing them is the prioity?

Gordon

[Adrian Kelland]

As a mildly interesting aside,

I did a first aid course with a paramedic about 3months ago and was told that 15:2 is the ideal ratio (it was at the time ...) but that he would rather have someone doing say 20:4 efficiently than someone sticking to 15:2 but acheiving naff all.

Is it really necessary to continually update ratios and speeds? Surely making sure people are doing it right and not confusing them is the prioity?

Gordon
If it can be bettered, it should.

So really should this be about effective at 20:4 and more effective at 15:2 and current best known effective at 30:2?

Adrian

[Tony F]

If it can be bettered, it should.


Seems blindingly obvious to me.

Keeping apprised of current best practise is really important with all diving related techniques but perhaps this one is the most important of all. I'm sure all of us hope we'll never need to use these skills in anger but............. and it could be at any time, even when Xmas shopping (you should see what my wife spends!).

The only thing on my wish list is that rescue/cpr/etc best practice should be standardised quickly across all agencies as a priority, I guess it takes time in different ways for each agency to work through new guidelines and issue them but these type should be top of the hit list.

[Andy Botten]

best practice should be standardised quickly across all agencies as a priority, I guess it takes time in different ways for each agency to work through new guidelines and issue them
AFAIK St Johns have a "cop out" their policy refers to the current Resus Council recomendations.

As a result I know I am going to be doing 30:2 tonight.

If BSAC do the same then there is no issue (other than amending all the slides for Sports, D/L(O2), Advanced Diver, RFA...

[Tony F]

AFAIK St Johns have a "cop out" their policy refers to the current Resus Council recomendations.

As a result I know I am going to be doing 30:2 tonight.

If BSAC do the same then there is no issue (other than amending all the slides for Sports, D/L(O2), Advanced Diver, RFA...

Cheers for that, it's very wise and makes good sense, printed material is expensive and has a long shelf life.

[Gordon]

But if you are jumping up and down at 30:2 and doing naff all, surely youd be better concentrating on making your breaths effective at 15:2 or 20:4 or whatever rate you can while your actually doing something constructive?

[Adrian Kelland]

But if you are jumping up and down at 30:2 and doing naff all, surely youd be better concentrating on making your breaths effective at 15:2 or 20:4 or whatever rate you can while your actually doing something constructive?
Yes,

but even better concentrating on doing 30:2 effectively.

[Gordon]

But there are some thick people about ;)

[Andy Botten]

But there are some thick people about ;)
True there is no Blood test for stupidity...

But there is:
Practice
Practice
Practice

[Gordon]

but what im suggesting is that practising making your efforts effective is more important than worrying about the exact ratio.

Having said that, if the guys with the knowledge say that it will be easier to be more effective at 30:2 ...

Im getting a bit hypocritical here arent I?

[Gordon]

Think I have sorted out the point that im trying to make.
The effectiveness of the breathes is more important than the rate at which they are delivered, but the textbook rates are targets to aim for.
If you dont reach 100comp/min or miss out a couple of compressions beacuse you have lost count, it is not the end of the world if your other 28compressions are effective.
Does this make more sense than my first couple of efforts?
Read them through and thought - 'thats not quite what I meant to say'

[MSutcliffe]

Please, for gods sake, don't get your knickers in a twist about all of this.

Im my humble opinion, you should do what you have been trained to do. Wait until you have had the opportunity to be re-trained, and practise with the new recommendations.

The absolute last thing I would want to see at the scene of a collapsed patient is folk arguing/obscessing about the ratio of compressions to breaths. These changes have potential to result in much confusion.

And remember, CPR alone is unlikely to save the life - your 1st priority is definitive care - ie, a Defibrilator, followed very rapidly by a hospital.

Now take every opportunity to practise this. Remember that folk doing this in Hospital, who maybe attend 4 or 5 per week are still required to do an update course every year to ensure their skills are up to scratch. The lay public cannot possibly hope to get that level of experience, so if you want ot be effective, you should try to take every opportunity to do it with your old friend Annie.

Hopefuly, the BSAC will rapidly disseminate the information to all instructors, and when they have their heads around it they can run training/practise sessions for the branch - I know I'll be running sessions for the branch at large in the new year.

The most anyone can possibly be expected to do is their best. You will not get sued, your will not be arrested/charged/punished. If anything, a grateful family will try to find out your name to say thankyou for your effort.

[MSutcliffe]

Dear All,

As I am running an O2 course this week, I sought confirmation on what to teach from BSAC HQ. I recieved the following reply. I'm sure it is reasonable to copy it here, by way of ensuring interested parties are updated, and hopefuly saving several similar emails to teh technical dept.

We are aware of the Guidelines. The various NDC Groups are assessing the proposals. Until you hear otherwise, use the existing recommendations.

Having re-read the 2005 guidelines a couple of times now, I have to say I have noted that any reference to a change in procedure for victims of drowining seems to have been removed, and there is certainly reference to suggestion that chest compressions are rather more important artificial ventilation.

i wonder how this impacts on diver training - should our rescue skills really be teaching folk to stop and do rescue breathing during their tow??? Or should we all just haul ass and get back to the boat/shore as fast as possible - where effective chest compressions can also be given??

Indeed the european resus councils recommendations are that the first level of life support training (bronze level) to the lay public should include ONLY chest compressions (NO rescue breathing).

[Tony Dwyer]

Apparently there was a study in Brazil about tow/rescue breathing and IIRC the survival rate doubled. The NDC are aware of this because the guy that told me that has talked to them about it. I would sit tight and wait for the updates to come through.
I think that the new guidelines will still include rescue breathing while towing but not doing rescue breathing while dekitting to speed up the chest compression bit. I think that the logic behind this is that you have enough O2 dissolved in your blood to survive for about 6mins, if you can move it round. But obviously you cant do this in the water. This is one of the limitations of the Brazil study - lifeguards dont have to dekit their casualties much....
DO NOT TAKE MY WORD FOR IT - DO WHAT BSAC SAY

I think you might be referring to this.

http://www.ilsf.org/medical/policy_07.htm

In the detail they mention % increases in survival, but they don't give numbers or describe the incidents involved. Fishing someone out of a swimming pool is a hell of a lot faster than bringing a diver up from 20 mtrs. Though I will agree that recovering a swimmer in surf is a really tough job.

Part of the difficulty I have with the idea of performing AV in the water is that we often have no idea what has caused the casualty to stop breathing. If it is an observed 'Out of Air' incident then the rescuer may know how long the casualty has been deprived of air. However, I understand that a significant number of non-breathing casualties still have air in their tanks. So another mechanism is the cause of them not breathing. Possibly panic perhaps. How many such casualties are caused by cardiac arrest underwater? I seem to recall that heart attacks are a significant cause of death in recreational divers. In such cases performing in-water AV is pointless. There is no circulation to provide O2 to the brain & other tissues. The casualties possible survival is dependent on full CPR being performed as rapidly as possible followed by debrillation and support by Paramedics ASAP. CPR is pretty much impossible in water, a firm surface is required.
Any extension of the time taken to get the casualty to a firm surface will lessen their already poor chance of recovery.

I understand that even with well trained people AV/CPR in the best of conditions is often less effective in real incidents than it appears to be when practising on a dummy. Add the complication of moving water and the high stress of a real incident then effectiveness is further compromised.

However, AV/CPR are core first aid skills that really do save lives and I believe that everyone should be trained to be competent in the techniques.

I would like to see some analysis of the causes of death of divers, where in-water AV has been attempted. I have a feeling that AV in water may be found not to be as effective as we have all been led to believe.

On two seperate occasions, I have towed an incapacitated diver (exhausted, not injured and they were not my buddies) from the end of Swanage pier to the shore. Long tows that pretty much wiped me out, I don't think that I could have performed CPR effectively afterwards. These experiences led me believe that should I have to perform a long tow in a real incident, ALL the kit will go right away to reduce drag.

Given a long tow to shore and I suspect no pulse, I would consider ditching all the kit and simply going for it.

[David Walker]

i wonder how this impacts on diver training - should our rescue skills really be teaching folk to stop and do rescue breathing during their tow??? Or should we all just haul ass and get back to the boat/shore as fast as possible - where effective chest compressions can also be given??

In the end, what BSAC currently teach hasn't suddenly become dangerous. It may no longer be considered the best approach, but it is obviously still effective and better than nothing. Until they tell us otherwise, we have to go with it I suppose, although on a recent course (SD I think) I mentioned after the end of the lecture that recomendations were changing and so not to get too worried about timings, ratios, etc...

The problem we've got is that, even if we wanted to, there's not much we can do to teach the "new" ways without BSAC anyway. The resus council don't give recommnedations for in-water AV and that kind of stuff, that needs to be assessed by BSAC / medical referees / etc. For a while now the recommendations on two-person CPR have been different, saying essentially that we should never do that... but we can't really teach it because BSAC haven't told us to, and there are complications like what do we do with O2-enriched CPR, etc?

Hopefully some nice clear guidance, with new slides and stuff too (to remove things like "check for cyanosis" which I believe has also been deemed ineffective for a long time now) will be with us very soon... and then we can run refreshers on it all for everyone! :)

David

[Andy Botten]

Having re-read the 2005 guidelines a couple of times now, I have to say I have noted that any reference to a change in procedure for victims of drowning seems to have been removed,

No: there is a section at the end of the document "Resuscitation of children & victims of drowning".
For these they explicitly recommend 5 breaths first then try for one minute before going for help.

HTH

[garethwebber]

Hi,

When I took my first aid at work course we talked about this.

The reason for the change in the 2005 requirements is that most adults do not suffer respiratory arrest, they suffer cardiac arrest and so moving to chest compressions is essential.

HOWEVER there are four cases where respiratory arrest can occur: Drowning, Injury, Choking and Kids. Notice the first. Thats why AV *may* be enough for diving incidents whereas it is unlikely to be enough for someone found not breathing in "real life".

I am with the majority - stick with what you have been taught until told otherwise as subtleties like this might mean diving advice is different to general first aid.

Gareth

[garethwebber]

Looks like the new guidelines are out:

http://www.bsac.org/techserv/irc/resupd06.htm

Gareth

[johnskerry]

what does the followow point mean

summon help, leaving the casualty if necessary

[Paul Beal]

It means that getting emergency help is a higher priority than starting resus. The figures show that the success rates are so much higher in professional hands so it is best to get them on their way.

St Johns have been teaching like that for about 10 years.

Paul

[Odin]

It means you will need the jump start kit and drugs...
The sooner you send for it, the sooner it arrives....

[johnskerry]

If someone else is there sure send for help, but if you are on your own , how long have you got to get help and get back before it’s to late ?

[Ben Thompson]

If someone else is there sure send for help, but if you are on your own , how long have you got to get help and get back before it’s to late ?

Well the idea behind that is that you can't restart a heart- you need a defib, so you go and get someone to bring you one.

Yes, I expect if you're up a mountain, and it's a three hour walk to get help, then something else would have to be done, but we should (as divers) pretty much always be in a position where we can call for help pretty much immediately, shouldn't we?

[Andy Botten]

leaving the casualty if necessary
If you've got a mobile phone & a signal, you won't have to leave him.
Or if you have a bystander, they can run off and summon help.
Having summoned help you are now free to push & puff until the cavalry arrive ;)

[PeteM]

Looks like the new guidelines are out:

http://www.bsac.org/techserv/irc/resupd06.htm

Gareth

OK, so a lot of the lectures slides and exams are now out of date - are HQ preparing revised versions or should we be doing this ourselves (no point in duplicating effort)

[Ant Slegg]

First I'd like to thank the BS-AC for ensuring that the membership has the very latest advice on such a crucial skill.

However secondly I'd like to raise a few points:

1) Some technical aspects of this training have changed (i.e. 30:2). Would it
be possible for the pdf/web-page to be updated to give people some idea
of why those changes have been made? I'm sure this would reduce the
number of questions asked significantly.

2) The information does seem to be a fairly straightforward copy of the
new top level advice.
However this causes problems when diving situations are considered:
Do the BS-AC really think that point 3a reads well in a diving context?
It has the following:
"...in which you found him..."
How often is a diving casualty "found"?
A revision of some of the wording with a little more direct thought as to
the context (diving) would make this document easier to digest.

3) On the web-page under "Major Changes" the following is stated:
"...place their hands in the centre of the chest..." - note centre
Then later in the section on "Basic Life Support Sequence" several
references are given with respect to hand position and the sternum.
These pieces of advice appear to be in conflict. Can someone at HQ
provide a clarification?

4) "In Water Life Support" has:
"...removed from the water by the fastest and safest...".
Given so much concern has been expressed over how the language is
interpreted can the emphasis on speed as being equally important as
safety be given some thought.

5) Can HQ confirm that "cardiac arrest" may be diagnosed in a breathing
casualty? (see Major changes). How long after cardiac arrest does
breathing cease?

6) Could the document be restructured so that emphasis is given to how to
deal with the more likely diving scenarios? Commonly for BS-AC divers this
means shore, RIB or hard-boat diving in a group with other divers capable
of CPR? The solo rescuer/victim scenario should be covered but it should
be made clear that diving without shore/boat cover is to be avoided in the
first place. Prevention is always better than cure.

7) For both this information (and for other training revisions in the future)
could the format of the PDF be made such that it can be introduced as a
direct substitution to the Instructor Manual? I.e. same layout, page
numbering. This would much simplify keeping the manual up to date.

8) If the centre of the chest is the preferred location how will this work with
the various types of Rescusitation doll used? Some don't give the audible
click or other indication if the location is poorly chosen (with respect to the
sternum). Can HQ recommend a make of doll that will work well with this
new technique?


Ant S

[garethwebber]

Hi Ant,

There is a whole thread looking at updating the training materials which cover most of your points.

http://www.bsacforum.co.uk/forums/showthread.php?t=4027

Gareth

[Ant Slegg]

Hi Ant,

There is a whole thread looking at updating the training materials which cover most of your points.

http://www.bsacforum.co.uk/forums/showthread.php?t=4027

Gareth

Gareth,
Updating the training material, whilst of course extremely useful, doesn't really cover my concerns. Updated training material based on what BS-AC have posted already will only reflect the problems/ambiguities contained in the orginal material. It's that original material which has to be whiter than white. If training material (especially stuff people have generously done "unofficially") leads to questions from Trainees that Instructors can't answer then that doesn't look good.



Ant

[Keith Lawrence]

Gareth,
Updating the training material, whilst of course extremely useful, doesn't really cover my concerns. Updated training material based on what BS-AC have posted already will only reflect the problems/ambiguities contained in the orginal material. It's that original material which has to be whiter than white. If training material (especially stuff people have generously done "unofficially") leads to questions from Trainees that Instructors can't answer then that doesn't look good.

AntThe DTP, any DTP, is a living and evolving document, it was never meant to be cast-in-stone and is always subject to revision and updating. We keep a list of all amendments since original publication over on http://www.bsac.org/techserv/irc/ircintro.htm, all instructors should keep up-to-date with that section, the recent changes will be added there as soon as possible.

HTH

Keith L

[Hamish]

Hi Ant,

I have tried to answer your points based on my interpretation and knowledge and are solely that, my interpretation and knowlege as a lay person, other people may have other opinions.


However secondly I'd like to raise a few points:

1) Some technical aspects of this training have changed (i.e. 30:2). Would it
be possible for the pdf/web-page to be updated to give people some idea
of why those changes have been made? I'm sure this would reduce the
number of questions asked significantly.
Ant S

As Keith and others have pointed out there are some very good people out there who are already looking into the revisions/updates they feel are required and I point out it is not just the idea’s of one person but a collection of people pooling there ideas and knowledge. These changes are being documented to show why and where the change is made, also as Keith has said these are not set in stone, you can make fundamental changes provided you keep within the guidelines laid down. Why not join them I did.


2) The information does seem to be a fairly straightforward copy of the
new top level advice.
However this causes problems when diving situations are considered:
Do the BS-AC really think that point 3a reads well in a diving context?
It has the following:
"...in which you found him..."
How often is a diving casualty "found"?
A revision of some of the wording with a little more direct thought as to
the context (diving) would make this document easier to digest.
Ant S

The context of this point is a casualty may not be specifically a casualty of drowning or cardiac arrest but may in fact be just suffering an ill effect of some other disorder, so is correct in its procedure as it also follows with ‘Try to find out what is wrong…’


3) On the web-page under "Major Changes" the following is stated:
"...place their hands in the centre of the chest..." - note centre
Then later in the section on "Basic Life Support Sequence" several
references are given with respect to hand position and the sternum.
These pieces of advice appear to be in conflict. Can someone at HQ
provide a clarification?
Ant S

OK you may not be aware but the Sternum or breastbone is the long, flat bone located in the centre of the thorax (chest) and runs the length of the chest top to bottom to which the ribs are connected. So by placing your hands over the centre of the chest you are in fact over the centre of the Sternum.


4) "In Water Life Support" has:
"...removed from the water by the fastest and safest...".
Given so much concern has been expressed over how the language is
interpreted can the emphasis on speed as being equally important as
safety be given some thought.
Ant S

The in-water life support begins with ‘ The Rescuers should be aware of there personal safety and minimise danger to themselves and the casualty at all times. As in all rescue scenarios this is the prime consideration but carrying it out in the fastest and safest method should also be briefed.


5) Can HQ confirm that "cardiac arrest" may be diagnosed in a breathing
casualty? (see Major changes). How long after cardiac arrest does
breathing cease?
Ant S

It is not for us as lay teachers, and that is what we are as BSAC instructors, to diagnose when breathing fails in cardiac arrest, but to teach the basic first aid procedures if we find that the casualty is unresponsive and not breathing.


6) Could the document be restructured so that emphasis is given to how to
deal with the more likely diving scenarios? Commonly for BS-AC divers this
means shore, RIB or hard-boat diving in a group with other divers capable
of CPR? The solo rescuer/victim scenario should be covered but it should
be made clear that diving without shore/boat cover is to be avoided in the
first place. Prevention is always better than cure.
Ant S

It is down to the instructor when lecturing theory and the practical sessions to cover each of the scenarios, which may or may not present themselves. The instructor will have been taught these on the SDC’s, which are required when teaching.


7) For both this information (and for other training revisions in the future)
could the format of the PDF be made such that it can be introduced as a
direct substitution to the Instructor Manual? I.e. same layout, page
numbering. This would much simplify keeping the manual up to date.
Ant S

On this I may agree, although for myself this poses no problem as using MSWord etc it is very easy to do.


8) If the centre of the chest is the preferred location how will this work with
the various types of Rescusitation doll used? Some don't give the audible
click or other indication if the location is poorly chosen (with respect to the
sternum). Can HQ recommend a make of doll that will work well with this
new technique?
Ant S

I for one do not listen for any noises when teaching but watch the technique used by the trainee and correct the technique where applicable, not all Resuscitation Anne’s have this facility.


Regards

Hamish :)

[garethwebber]

To be honest, I am some of the other externally trained first aiders are suprised how far BSAC has shifted.

BSAC seems to have pretty much followed the resus guidelines without much adjustment for diving. The guidelines are designed for the average person finding a casualty on a street (hence some of the language). The likelyhood here, especially with an increasingly elderly population, is cardiac arrest and the only way of saving them is to get a defib to the quickly and get them to hospital for stabilisation.

Basic life support, if it hinders getting a defib, does not help. (Obviously if there are enough of you to go get a defib and do life support then life support is a good thing)

The situation with divers is different. Accidents are usually DCI or drowning. Something useful can be done by basic life support (well AV, preferably oxygen assisted) in these cases. All the pre-2005 first aid books, in their life support flowcharts have "is this this a drowning, choking, injury or kid? Then do something different option."

That said, I do NOT know the incidents stats as well as those who will have made this decision so while I am a little suprised, I will be adjusting my technique to match what is taught.

Gareth

[Ant Slegg]

Keith L wrote:
The DTP, any DTP, is a living and evolving document, it was never meant to be cast-in-stone and is always subject to revision and updating. We keep a list of all amendments since original publication over on http://www.bsac.org/techserv/irc/ircintro.htm, all instructors should keep up-to-date with that section, the recent changes will be added there as soon as possible.


--------------
What concerned me was not the fact that the training evolves but the fact that the BS-AC have changed something this fundamental without having the materials generally used in training ready at the same time. I don't believe that the role of the membership is to generate the OD/SD etc. materials and distribute them, this surely is the task of HQ?

[Gareth]

Ant

I don't think you are being entirely fair. The BSAC is a members Club.

The DTP & the SDC's are written by the members. Under the guidence of NDC, who are all volunters.

see http://www.bsac.org/techserv/ndc/ndcplan.htm

In the case of the revisions to AV CC (Rescue Breathing). There was a push /question from the membership on the forum, the responsible part of NDC reviewed the new publications & responded with the new BSAC recomendations. The membership modified the slides.

In my mind I think the speed of response was impressive! It also shows what a members club is about.

Gareth