• D: remove from danger
• R: assess patient responsiveness
• S: send for help
• A: clear airway
  • head tilt-chin lift if non-trauma, or jaw thrust if trauma
  • remove vomitus using suction if possible
  • recognition and relief of foreign body airway obstruction
• B: restore breathing although no longer the priority in adult out-of-hospital arrest
  • cardiac compressions alone (no ventilations) recommended for adult, out-of-hospital primary cardiac arrest (not respiratory) if witnessed, and with shockable rhythm or short period (<4 minutes) of untreated arrest
  • cardiac compressions alone also recommended if bystander not trained in CPR, or not confident in their ability
  • breaths (in hospital or those trained in CPR):
    • bag and mask if available (and oxygen at 15L/min to deliver 85% oxygen if available)
    • 2 effective breaths every 30 compressions with a 1 second inspiratory time (except neonates, give 40-60 breaths/min)
      • if unprotected airway, pause compressions during breaths
      • if protected airway (eg. ETT in situ), don't pause compressions, and rate should 1 breath every 15 compressions (2 breaths in children every 15 compressions)
    • bag size:
      • > 18kg or > 5yrs old, use a 1600ml adult bag
      • infant, use a 500ml bag
      • neonate, use a 240ml bag or neonatal circuit
• C: establish circulation:
  • checking for pulses is unreliable, instead start compressions if no signs of life, for instance:
    • unresponsive or unconscious
    • not breathing or the occasional gasping breath
    • not moving
  • cardiac compressions over mid-sternum to a depth of 1/3rd chest (eg. 4-5cm in an adult) at a rate of 100 per minute for all ages, stopping to allow 2 breaths every 30 compressions if unprotected airway
  • early cardiac compressions may:
    • prevent VF deteriorating into asystole
    • increase the chance of successful defibrillation in VF
    • add to the preservation of brain and cardiac function
• D: availability of semi-automatic external defibrillators:
  • defibrillation as soon as possible provides the best chance of survival in victims with VF or pulseless VT
  • see Mx of pulseless VT or VF
  • C/I to SAED (await ALS team instead):
    • children < 8yrs age or < 25kg
    • unsafe environment
    • conscious and breathing normally
• if cardiac arrest occurs in the obviously pregnant woman, place in a left lateral tilt by placing a pillow or wedge under the right buttock - this will reduce compression of IVC and aid venous return.

• continues the principles of BLS but then splits depending on:
  • shockable rhythm
    • see Mx of pulseless VT or VF
  • non-shockable rhythm (asystole or PEA)
    • see pulseless electrical activity (PEA)/(EMD)
    • if asystole:
      • adrenaline / epinephrine 1mg (10mcg/kg) boluses stat then every 2nd 2 minute CPR cycle
  • return of spontaneous circulation (ROSC)
    • see also:
      • bradycardia
      • cardiac arrhythmias
      • return of spontaneous circulation (ROSC) post-arrest
• if likely poisoning or toxin then consider specific therapies:
  • good CPR (cardioversion/defibrillation unlikely to help)
  • call an expert on toxicological arrests ASAP if possible
  • give boluses iv sodium bicarbonate 1-2mEq/kg every 1-2 minutes until return of perfusing rhythm
  • intubate and hyperventilate
  • give adrenaline as per usual cardiac arrest protocol
  • avoid amiodarone
  • consider 20% intralipid 100ml over 1 minute, repeat once or twice in 3-5 minute intervals if required, followed by an infusion
  • keep doing CPR
  • beta adrenergic blocker overdose or calcium channel blocker overdose then consider atropine and high dose insulin and dextrose Rx
  • Acetylcholinesterase inhibitor poisoning - then high dose atropine and perhaps pralidoxime
  • digoxin toxicity - Fab fragments
  • tricyclic antidepressant overdose or other sodium channel blocker - consider sodium bicarbonate
  • local anaesthetic agents overdose - iv lipid emulsion therapy - 1.5ml/kg bolus of 20% lipid emulsion, then 0.25-0.5ml/kg/min infusion¹⁾
  • Envenomation and bites - consider antivenom

• intubation should not interrupt chest compressions for more than 20 seconds
• avoid hyperventilation as risk of complications from increased intrathoracic pressure, and decreased coronary and cerebral perfusion.
• ventilation rate once intubated should usually be 8-10 breaths/minute, without pausing for chest compressions (rate 15:1)
• confirmation of correct endotracheal tubbe placement - eg. end-tital CO₂

• International Liaison Committee on Resuscitation (ILCOR)
  • Recommendations: Resuscitation 2005; 67: 157-342
• European Resuscitation Council Guidelines
  • recommendations: Resuscitation 2005; 67 (Suppl 1):S1-S190
• American Heart Association (AHA)
  • Recommendations - Circulation 2005; 112: IV-1 - IV-211
• Australian Resuscitation Council (ARC)
• New Zealand Resuscitation Council (NZRC)

Mr Bean - CPR at the bus stop