The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [383]
Evidence-based approaches
Sudden death as a result of cardiac arrest is responsible for 60% of ischaemic heart disease deaths across Europe (Resuscitation Council 2010b). Survival to hospital discharge is cited as 10.7% of all types of cardiac arrest with survival being higher (21.2%) in ventricular fibrillation arrests (Resuscitation Council 2010b).
Changes to adult basic life support (BLS) guidelines have been made to reflect the importance of performing high quality chest compressions. The rescuer should reduce the number and duration of pauses during chest compressions (Resuscitation Council 2010b).
Cardiopulmonary resuscitation guidelines in the UK are researched and implemented by the Resuscitation Council UK, and BLS and ALS guidelines are changed according to their recommendations. Although the Resuscitation Council guidelines of 2000 recommended immediate defibrillation for all shockable rhythms, evidence indicates that a period of CPR before defibrillation may improve survival after prolonged collapse (>5 min) (Wik et al. 2003). The duration of collapse is frequently difficult to estimate accurately, so CPR should be given before attempted defibrillation outside hospital, unless the arrest is witnessed by a healthcare professional or an automated external defibrillator (AED) is being used (Resuscitation Council 2010b).
In contrast, there is no evidence to support or refute the use of CPR before defibrillation for in-hospital cardiac arrest. For this reason, after in-hospital VF/VT cardiac arrest, a shock should be given as soon as possible (Resuscitation Council 2010b). Continuing good-quality CPR may improve the amplitude and frequency of fine VF and improve the chance of successful defibrillation to a perfusing rhythm, as fine VF is difficult to distinguish from asystole and very unlikely to be shocked successfully.
Rationale
The basic technique involves a rapid simple assessment of the patient followed by the basic life support (BLS) resuscitation. The first international consensus evidence-based guidelines on resuscitation were published in 2000 (AHA/ILCOR 2010, Shuster et al. 2010). These guidelines were reviewed in 2004/05 by the International Liaison Committee on Resuscitation and published in 2005 (AHA/ILCOR 2010). These internationally agreed guidelines based on research and audit now form the basis for the European resuscitation guidelines (Baskett et al. 2005) as well as the UK resuscitation guidelines (Resuscitation Council 2010b).
Changes to Resuscitation Council UK guidelines suggest that the rescuer should not stop to check the patient or discontinue CPR unless the person starts to show signs of regaining consciousness, such as coughing, opening eyes, speaking or moving purposefully and starts to breathe normally (Resuscitation Council 2010b).
Indications
The patient is unconscious, has absent or agonal (gasping) respirations and has no pulse (Perkins et al. 2005). Other clinical features such as pupil size, cyanosis and pallor are unreliable and so the practitioner should not waste time looking for them (Skinner and Vincent 1997).
Contraindications
Do not attempt resuscitation orders (DNAR) (Box 10.1).
If the environment is going to place the rescuer at risk, do not attempt resuscitation until environment secured.
Box 10.1 Decision making: do not attempt resuscitation (DNAR)
In an attempt to reduce the number of futile resuscitation attempts, many hospitals have introduced formal DNAR policies, which can be applied to individual patients in specific circumstances. Healthcare professionals must be able to show that their decisions relating to CPR are compatible with the human rights set out in the Human