European Resuscitation Council Guidelines for Resuscitation 2015: Section 1. Executive summary

Koenraad G. Monsieurs ^a ^b ^⁎ , Jerry P. Nolan ^c ^d, Leo L. Bossaert ^e, Robert Greif ^f ^g, Ian K. Maconochie ^h, Nikolaos I. Nikolaou ⁱ, Gavin D. Perkins ^j ^p, Jasmeet Soar ^k, Anatolij Truhlář ^l ^m, Jonathan Wyllie ⁿ and David A. Zideman ^o on behalf of the ERC Guidelines 2015 Writing Group¹ (Gamal Eldin Abbas Khalifa, Annette Alfonzo, Hans-Richard Arntz, Helen Askitopoulou, Abdelouahab Bellou, Farzin Beygui, Dominique Biarent, Robert Bingham, Joost J.L.M. Bierens, Bernd W. Böttiger, Leo L. Bossaert, Guttorm Brattebø, Hermann Brugger, Jos Bruinenberg, Alain Cariou, Pierre Carli, Pascal Cassan, Maaret Castrén, Athanasios F. Chalkias, Patricia Conaghan, Charles D. Deakin, Emmy D.J. De Buck, Joel Dunning, Wiebe De Vries, Thomas R. Evans, Christoph Eich, Jan-Thorsten Gräsner, Robert Greif, Christina M. Hafner, Anthony J. Handley, Kirstie L. Haywood, Silvija Hunyadi-Antičević, Rudolph W. Koster, Anne Lippert, David J. Lockey, Andrew S. Lockey, Jesús López-Herce, Carsten Lott, Ian K. Maconochie, Spyros D. Mentzelopoulos, Daniel Meyran, Koenraad G. Monsieurs, Nikolaos I. Nikolaou, Jerry P. Nolan, Theresa Olasveengen, Peter Paal, Tommaso Pellis, Gavin D. Perkins, Thomas Rajka, Violetta I. Raffay, Giuseppe Ristagno, Antonio Rodríguez-Núñez, Charles Christoph Roehr, Mario Rüdiger, Claudio Sandroni, Susanne Schunder-Tatzber, Eunice M. Singletary, Markus B. Skrifvars, Gary B. Smith, Michael A. Smyth, Jasmeet Soar, Karl-Christian Thies, Daniele Trevisanuto, Anatolij Truhlář, Philippe G. Vandekerckhove, Patrick Van de Voorde, Kjetil Sunde, Berndt Urlesberger, Volker Wenzel, Jonathan Wyllie, Theodoros T. Xanthos and David A. Zideman).

Resuscitation, October 2015, Pages 1 - 80

Introduction

This executive summary provides the essential treatment algorithms for the resuscitation of children and adults and highlights the main guideline changes since 2010. Detailed guidance is provided in each of the ten sections, which are published as individual papers within this issue of Resuscitation. The sections of the ERC Guidelines 2015 are:

1. Executive summary
2. Adult basic life support and automated external defibrillation¹
3. Adult advanced life support²
4. Cardiac arrest in special circumstances³
5. Post-resuscitation care⁴
6. Paediatric life support⁵
7. Resuscitation and support of transition of babies at birth⁶
8. Initial management of acute coronary syndromes⁷
9. First aid⁸
10. Principles of education in resuscitation⁹
11. The ethics of resuscitation and end-of-life decisions¹⁰

The ERC Guidelines 2015 that follow do not define the only way that resuscitation can be delivered; they merely represent a widely accepted view of how resuscitation should be undertaken both safely and effectively. The publication of new and revised treatment recommendations does not imply that current clinical care is either unsafe or ineffective.

Summary of the changes since the 2010 Guidelines

Adult basic life support and automated external defibrillation

The ERC Guidelines 2015 highlight the critical importance of the interactions between the emergency medical dispatcher, the bystander who provides CPR and the timely deployment of an AED. An effective, co-ordinated community response that draws these elements together is key to improving survival from out-of-hospital cardiac arrest ( Fig. 1.1 ).
The emergency medical dispatcher plays an important role in the early diagnosis of cardiac arrest, the provision of dispatcher-assisted CPR (also known as telephone CPR), and the location and dispatch of an AED.
The bystander who is trained and able should assess the collapsed victim rapidly to determine if the victim is unresponsive and not breathing normally and then immediately alert the emergency services.
The victim who is unresponsive and not breathing normally is in cardiac arrest and requires CPR. Bystanders and emergency medical dispatchers should be suspicious of cardiac arrest in any patient presenting with seizures and should carefully assess whether the victim is breathing normally.
CPR providers should perform chest compressions for all victims in cardiac arrest. CPR providers trained and able to perform rescue breaths should combine chest compressions and rescue breaths. Our confidence in the equivalence between chest compression-only and standard CPR is not sufficient to change current practice.
High-quality CPR remains essential to improving outcomes. The guidelines on compression depth and rate have not changed. CPR providers should ensure chest compressions of adequate depth (at least 5 cm but no more than 6 cm) with a rate of 100–120 compressions min⁻¹. After each compression allow the chest to recoil completely and minimise interruptions in compressions. When providing rescue breaths/ventilations spend approximately 1 s inflating the chest with sufficient volume to ensure the chest rises visibly. The ratio of chest compressions to ventilations remains 30:2. Do not interrupt chest compressions for more than 10 s to provide ventilations.
Defibrillation within 3–5 min of collapse can produce survival rates as high as 50–70%. Early defibrillation can be achieved through CPR providers using public access and on-site AEDs. Public access AED programmes should be actively implemented in public places that have a high density of citizens.
The adult CPR sequence can be used safely in children who are unresponsive and not breathing normally. Chest compression depths in children should be at least one third of the depth of the chest (for infants that is 4 cm, for children 5 cm).
A foreign body causing severe airway obstruction is a medical emergency and requires prompt treatment with back blows and, if that fails to relieve the obstruction, abdominal thrusts. If the victim becomes unresponsive CPR should be started immediately whilst help is summoned.

Fig. 1.1 The interactions between the emergency medical dispatcher, the bystander who provides CPR and the timely use of an automated external defibrillator are the key ingredients for improving survival from out of hospital cardiac arrest.

Adult advanced life support

The ERC 2015 ALS Guidelines emphasise improved care and implementation of the guidelines in order to improve patient focused outcomes.¹¹ The key changes since 2010 are:

Continued emphasis on the use of rapid response systems for care of the deteriorating patient and prevention of in-hospital cardiac arrest.
Continued emphasis on minimally interrupted high-quality chest compressions throughout any ALS intervention: chest compressions are paused briefly only to enable specific interventions. This includes minimising interruptions in chest compressions for less than 5 s to attempt defibrillation.
Keeping the focus on the use of self-adhesive pads for defibrillation and a defibrillation strategy to minimise the preshock pause, although we recognise that defibrillator paddles are used in some settings.
There is a new section on monitoring during ALS with an increased emphasis on the use of waveform capnography to confirm and continually monitor tracheal tube placement, quality of CPR and to provide an early indication of return of spontaneous circulation (ROSC).
There are a variety of approaches to airway management during CPR and a stepwise approach based on patient factors and the skills of the rescuer is recommended.
The recommendations for drug therapy during CPR have not changed, but there is greater equipoise concerning the role of drugs in improving outcomes from cardiac arrest.
The routine use of mechanical chest compression devices is not recommended, but they are a reasonable alternative in situations where sustained high-quality manual chest compressions are impractical or compromise provider safety.
Peri-arrest ultrasound may have a role in identifying reversible causes of cardiac arrest.
Extracorporeal life support techniques may have a role as a rescue therapy in selected patients where standard ALS measures are not successful.

Cardiac arrest in special circumstances

Special causes

This section has been structured to cover the potentially reversible causes of cardiac arrest that must be identified or excluded during any resuscitation. They are divided into two groups of four – 4Hs and 4Ts: hypoxia; hypo-/hyperkalaemia and other electrolyte disorders; hypo-/hyperthermia; hypovolaemia; tension pneumothorax; tamponade (cardiac); thrombosis (coronary and pulmonary); toxins (poisoning).

Survival after an asphyxia-induced cardiac arrest is rare and survivors usually have severe neurological impairment. During CPR, early effective ventilation of the lungs with supplementary oxygen is essential.
A high degree of clinical suspicion and aggressive treatment can prevent cardiac arrest from electrolyte abnormalities. The new algorithm provides clinical guidance to emergency treatment of life-threatening hyperkalaemia.
Hypothermic patients without signs of cardiac instability can be rewarmed externally using minimally invasive techniques. Patients with signs of cardiac instability should be transferred directly to a centre capable of extracorporeal life support (ECLS).
Early recognition and immediate treatment with intramuscular adrenaline remains the mainstay of emergency treatment for anaphylaxis.
A new treatment algorithm for traumatic cardiac arrest was developed to prioritise the sequence of life-saving measures.
Transport with continuing CPR may be beneficial in selected patients where there is immediate hospital access to the catheterisation laboratory and experience in percutaneous coronary intervention (PCI) with ongoing CPR.
Recommendations for administration of fibrinolytics when pulmonary embolism is the suspected cause of cardiac arrest remain unchanged.

Special environments

The special environments section includes recommendations for the treatment of cardiac arrest occurring in specific locations. These locations are specialised healthcare facilities (e.g. operating theatre, cardiac surgery, catheterisation laboratory, dialysis unit, dental surgery), commercial airplanes or air ambulances, field of play, outside environment (e.g. drowning, difficult terrain, high altitude, avalanche burial, lightning strike and electrical injuries) or the scene of a mass casualty incident.

A new section covers the common causes and relevant modification to resuscitative procedures in patients undergoing surgery.
In patients following major cardiac surgery, key to successful resuscitation is recognising the need to perform immediate emergency resternotomy, especially in the context of tamponade or haemorrhage, where external chest compressions may be ineffective.
Cardiac arrest from shockable rhythms (ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT)) during cardiac catheterisation should immediately be treated with up to three stacked shocks before starting chest compressions. Use of mechanical chest compression devices during angiography is recommended to ensure high-quality chest compressions and to reduce the radiation burden to personnel during angiography with ongoing CPR.
AEDs and appropriate CPR equipment should be mandatory on board of all commercial aircraft in Europe, including regional and low-cost carriers. Consider an over-the-head technique of CPR if restricted access precludes a conventional method.
Sudden and unexpected collapse of an athlete on the field of play is likely to be cardiac in origin and requires rapid recognition and early defibrillation.
Submersion exceeding 10 min is associated with poor outcome. Bystanders play a critical role in early rescue and resuscitation. Resuscitation strategies for those in respiratory or cardiac arrest continue to prioritise oxygenation and ventilation.
The chances of good outcome from cardiac arrest in difficult terrain or mountains may be reduced because of delayed access and prolonged transport. There is a recognised role of air rescue and availability of AEDs in remote but often-visited locations.
The cut-off criteria for prolonged CPR and extracorporeal rewarming of avalanche victims in cardiac arrest have become more stringent to reduce the number of futile cases treated with extracorporeal life support (ECLS).
Safety measures are emphasised when providing CPR to the victim of an electrical injury.
During mass casualty incidents (MCIs), if the number of casualties overwhelms healthcare resources, withhold CPR for those without signs of life.

Special patients

The section on special patients gives guidance for CPR in patients with severe comorbidities (asthma, heart failure with ventricular assist devices, neurological disease, obesity) and those with specific physiological conditions (pregnancy, elderly people).

In patients with ventricular assist devices (VADs), confirmation of cardiac arrest may be difficult. If during the first 10 days after surgery, cardiac arrest does not respond to defibrillation, perform resternotomy immediately.
Patients with subarachnoid haemorrhage may have ECG changes that suggest an acute coronary syndrome (ACS). Whether a computed tomography (CT) brain scan is done before or after coronary angiography will depend on clinical judgement.
No changes to the sequence of actions are recommended in resuscitation of obese patients, but delivery of effective CPR may be challenging. Consider changing rescuers more frequently than the standard 2-min interval. Early tracheal intubation is recommended.
For the pregnant woman in cardiac arrest, high-quality CPR with manual uterine displacement, early ALS and delivery of the foetus if early return of spontaneous circulation (ROSC) is not achieved remain key interventions.

Post-resuscitation care

This section is new to the European Resuscitation Council Guidelines; in 2010 the topic was incorporated into the section on ALS.¹² The ERC has collaborated with the European Society of Intensive Care Medicine to produce these post-resuscitation care guidelines, which recognise the importance of high-quality post-resuscitation care as a vital link in the Chain of Survival.¹³

The most important changes in post-resuscitation care since 2010 include:

There is a greater emphasis on the need for urgent coronary catheterisation and percutaneous coronary intervention (PCI) following out-of-hospital cardiac arrest of likely cardiac cause.
Targeted temperature management remains important but there is now an option to target a temperature of 36 °C instead of the previously recommended 32–34 °C. The prevention of fever remains very important.
Prognostication is now undertaken using a multimodal strategy and there is emphasis on allowing sufficient time for neurological recovery and to enable sedatives to be cleared.
A novel section has been added which addresses rehabilitation after survival from a cardiac arrest. Recommendations include the systematic organisation of follow-up care, which should include screening for potential cognitive and emotional impairments and provision of information.

Paediatric life support

Guideline changes have been made in response to convincing new scientific evidence and, by using clinical, organisational and educational findings, they have been adapted to promote their use and ease for teaching.

Basic life support

The duration of delivering a breath is about 1 s, to coincide with adult practice.
For chest compressions, the lower sternum should be depressed by at least one third the anterior-posterior diameter of the chest (4 cm for the infant and 5 cm for the child).

Managing the seriously ill child

If there are no signs of septic shock, then children with a febrile illness should receive fluid with caution and reassessment following its administration. In some forms of septic shock, restricting fluids with isotonic crystalloid may be of benefit as compared to liberal use of fluids.
For cardioversion of a supraventricular tachycardia (SVT), the initial dose has been revised to 1 J kg^-1.

Paediatric cardiac arrest algorithm

Many of the features are common with adult practice.

Post-resuscitation care

Prevent fever in children who have return of spontaneous circulation (ROSC) from an out-of-hospital setting.
Targeted temperature management of children post-ROSC should be either normothermia or mild hypothermia.
There is no single predictor for when to stop resuscitation.

Resuscitation and support of transition of babies at birth

The following are the main changes that have been made to the ERC guidelines for resuscitation at birth in 2015:

Support of transition: Recognising the unique situation of the baby at birth, who rarely requires resuscitation but sometimes needs medical help during the process of postnatal transition. The term support of transition has been introduced to better distinguish between interventions that are needed to restore vital organ functions (resuscitation) or to support transition.
Cord clamping: For uncompromised babies, a delay in cord clamping of at least 1 min from the complete delivery of the infant, is now recommended for term and preterm babies. As yet there is insufficient evidence to recommend an appropriate time for clamping the cord in babies who require resuscitation at birth.
Temperature: The temperature of newly born non-asphyxiated infants should be maintained between 36.5 °C and 37.5 °C after birth. The importance of achieving this has been highlighted and reinforced because of the strong association with mortality and morbidity. The admission temperature should be recorded as a predictor of outcome as well as a quality indicator.
Maintenance of temperature: At <32 weeks gestation, a combination of interventions may be required in addition to maintain the temperature between 36.5 °C and 37.5 °C after delivery through admission and stabilisation. These may include warmed humidified respiratory gases, increased room temperature plus plastic wrapping of body and head, plus thermal mattress or a thermal mattress alone, all of which have been effective in reducing hypothermia.
Optimal assessment of heart rate: It is suggested in babies requiring resuscitation that the ECG can be used to provide a rapid and accurate estimation of heart rate.
Meconium: Tracheal intubation should not be routine in the presence of meconium and should only be performed for suspected tracheal obstruction. The emphasis should be on initiating ventilation within the first minute of life in non-breathing or ineffectively breathing infants and this should not be delayed.
Air/oxygen: Ventilatory support of term infants should start with air. For preterm infants, either air or a low concentration of oxygen (up to 30%) should be used initially. If, despite effective ventilation, oxygenation (ideally guided by oximetry) remains unacceptable, use of a higher concentration of oxygen should be considered.
CPAP: Initial respiratory support of spontaneously breathing preterm infants with respiratory distress may be provided by CPAP rather than intubation.

Acute coronary syndromes

The following is a summary of the most important new views and changes in recommendations for the diagnosis and treatment of acute coronary syndromes (ACS).

Diagnostic Interventions in ACS

Pre-hospital recording of a 12-lead electrocardiogram (ECG) is recommended in patients with suspected ST segment elevation acute myocardial infarction (STEMI). For those with STEMI this expedites pre-hospital and in-hospital reperfusion and reduces mortality.
Non-physician ECG STEMI interpretation with or without the aid of computer ECG STEMI interpretation is suggested if adequate diagnostic performance can be maintained through carefully monitored quality assurance programmes.
Pre-hospital STEMI activation of the catheterisation laboratory may not only reduce treatment delays but may also reduce patient mortality.
The use of negative high-sensitivity cardiac troponins (hs-cTn) during initial patient evaluation cannot be used as a standalone measure to exclude an ACS, but in patients with very low risk scores may justify early discharge.

Therapeutic Interventions in ACS

Adenosine diphosphate (ADP) receptor antagonists (clopidogrel, ticagrelor, or prasugrel-with specific restriction), may be given either pre-hospital or in the ED for STEMI patients planned for primary PCI.
Unfractionated heparin (UFH) can be administered either in the pre-hospital or in-hospital setting in patients with STEMI and a planned primary PCI approach.
Pre-hospital enoxaparin may be used as an alternative to pre-hospital UFH for STEMI.
Patients with acute chest pain with presumed ACS do not need supplemental oxygen unless they present with signs of hypoxia, dyspnoea, or heart failure.

Reperfusion decisions in STEMI

Reperfusion decisions have been reviewed in a variety of possible local situations.

When fibrinolysis is the planned treatment strategy, we recommend using pre-hospital fibrinolysis in comparison to in-hospital fibrinolysis for STEMI where transport times are >30 min and pre-hospital personnel are well trained.
In geographic regions where PCI facilities exist and are available, direct triage and transport for PCI is preferred to pre-hospital fibrinolysis for STEMI.
Patients presenting with STEMI in the emergency department (ED) of a non-PCI capable hospital should be transported immediately to a PCI centre provided that treatment delays for PPCI are less than 120 min (60–90 min for early presenters and those with extended infarctions), otherwise patients should receive fibrinolysis and be transported to a PCI centre.
Patients who receive fibrinolytic therapy in the emergency department of a non-PCI centre should be transported if possible for early routine angiography (within 3–24 h from fibrinolytic therapy) rather than be transported only if indicated by the presence of ischaemia.
PCI in less than 3 h following administration of fibrinolytics is not recommended and can be performed only in case of failed fibrinolysis.

Hospital reperfusion decisions after return of spontaneous circulation

We recommend emergency cardiac catheterisation lab evaluation (and immediate PCI if required), in a manner similar to patients with STEMI without cardiac arrest, in selected adult patients with ROSC after out-of-hospital cardiac arrest (OHCA) of suspected cardiac origin with ST-elevation on ECG.
In patients who are comatose and with ROSC after OHCA of suspected cardiac origin without ST-elevation on ECG It is reasonable to consider an emergency cardiac catheterisation lab evaluation in patients with the highest risk of coronary cause cardiac arrest.

First aid

A section on first aid is included for the first time in the 2015 ERC Guidelines.

Principles of education in resuscitation

The following is a summary of the most important new views or changes in recommendations for education in resuscitation since the last ERC guidelines in 2010.

Training

In centres that have the resources to purchase and maintain high fidelity manikins, we recommend their use. The use of lower fidelity manikins however is appropriate for all levels of training on ERC courses.
Directive CPR feedback devices are useful for improving compression rate, depth, release, and hand position. Tonal devices improve compression rates only and may have a detrimental effect on compression depth while rescuers focus on the rate.
The intervals for retraining will differ according to the characteristics of the participants (e.g. lay or healthcare). It is known that CPR skills deteriorate within months of training and therefore annual retraining strategies may not be frequent enough. Whilst optimal intervals are not known, frequent ‘low dose’ retraining may be beneficial.
Training in non-technical skills (e.g. communication skills, team leadership and team member roles) is an essential adjunct to the training of technical skills. This type of training should be incorporated into life support courses.
Ambulance service dispatchers have an influential role to play in guiding lay rescuers how to deliver CPR. This role needs specific training in order to deliver clear and effective instructions in a stressful situation.

Implementation

Data-driven performance-focused debriefing has been shown to improve performance of resuscitation teams. We highly recommend its use for teams managing patients in cardiac arrest.
Regional systems including cardiac arrest centres are to be encouraged, as there is an association with increased survival and improved neurological outcome in victims of out-of-hospital cardiac arrest.
Novel systems are being developed to alert bystanders to the location of the nearest AED. Any technology that improves the delivery of swift bystander CPR with rapid access to an AED is to be encouraged.
“It takes a system to save a life” [ http://www.resuscitationacademy.com/ ]. Healthcare systems with a responsibility for the management of patients in cardiac arrest (e.g. EMS organisations, cardiac arrest centres) should evaluate their processes to ensure that they are able to deliver care that ensures the best achievable survival rates.

The ethics of resuscitation and end-of-life decisions

The 2015 ERC Guidelines include a detailed discussion of the ethical principles underpinning cardiopulmonary resuscitation.

The international consensus on cardiopulmonary resuscitation science

The International Liaison Committee on Resuscitation (ILCOR, www.ilcor.org ) includes representatives from the American Heart Association (AHA), the European Resuscitation Council (ERC), the Heart and Stroke Foundation of Canada (HSFC), the Australian and New Zealand Committee on Resuscitation (ANZCOR), the Resuscitation Council of Southern Africa (RCSA), the Inter-American Heart Foundation (IAHF), and the Resuscitation Council of Asia (RCA). Since 2000, researchers from the ILCOR member councils have evaluated resuscitation science in 5-yearly cycles. The most recent International Consensus Conference was held in Dallas in February 2015 and the published conclusions and recommendations from this process form the basis of these ERC Guidelines 2015.¹⁴

In addition to the six ILCOR task forces from 2010 (basic life support (BLS); advanced life support (ALS); acute coronary syndromes (ACS); paediatric life support (PLS); neonatal life support (NLS); and education, implementation and teams (EIT)) a First Aid task force was created. The task forces identified topics requiring evidence evaluation and invited international experts to review them. As in 2010, a comprehensive conflict of interest (COI) policy was applied.¹⁴

For each topic, two expert reviewers were invited to undertake independent evaluations. Their work was supported by a new and unique online system called SEERS (Scientific Evidence Evaluation and Review System), developed by ILCOR. To assess the quality of the evidence and the strength of the recommendations, ILCOR adopted the GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology.¹⁵ The ILCOR 2015 Consensus Conference was attended by 232 participants representing 39 countries; 64% of the attendees came from outside the United States. This participation ensured that this final publication represents a truly international consensus process. During the three years leading up to this conference, 250 evidence reviewers from 39 countries reviewed thousands of relevant, peer-reviewed publications to address 169 specific resuscitation questions, each in the standard PICO (Population, Intervention, Comparison, Outcome) format. Each science statement summarised the experts’ interpretation of all relevant data on the specific topic and the relevant ILCOR task force added consensus draft treatment recommendations. Final wording of science statements and treatment recommendations was completed after further review by ILCOR member organisations and by the editorial board, and published in Resuscitation and Circulation as the 2015 Consensus on Science and Treatment Recommendations (CoSTR).^{16 and 17} The member organisations forming ILCOR will publish resuscitation guidelines that are consistent with this CoSTR document, but will also consider geographic, economic and system differences in practice, and the availability of medical devices and drugs.

From science to guidelines

These ERC Guidelines 2015 are based on the 2015 CoSTR document and represent consensus among the members of the ERC General Assembly. New to the ERC Guidelines 2015 are the First Aid Guidelines, created in parallel with the First Aid Task Force of ILCOR, and guidelines on post-resuscitation care. For each section of the ERC Guidelines 2015, a writing group was assigned that drafted and agreed on the manuscript prior to approval by the General Assembly and the ERC Board. In areas where ILCOR had not conducted a systematic review, the ERC writing group undertook focused literature reviews. The ERC considers these new guidelines to be the most effective and easily learned interventions that can be supported by current knowledge, research and experience. Inevitably, even within Europe, differences in the availability of drugs, equipment, and personnel will necessitate local, regional and national adaptation of these guidelines. Some of the recommendations made in the ERC Guidelines 2010 remain unchanged in 2015, either because no new studies have been published or because new evidence since 2010 has merely strengthened the evidence that was already available.

Adult basic life support and automated external defibrillation

The basic life support (BLS) and automated external defibrillation (AED) chapter contains guidance on the techniques used during the initial resuscitation of an adult cardiac arrest victim. This includes BLS (airway, breathing and circulation support without the use of equipment other than a protective device) and the use of an AED. In addition, simple techniques used in the management of choking (foreign body airway obstruction) are included. Guidelines for the use of manual defibrillators and starting in-hospital resuscitation are found in section 3.² A summary of the recovery position is included, with further information provided in the First Aid Chapter.

The guidelines are based on the ILCOR 2015 Consensus on Science and Treatment Recommendations (CoSTR) for BLS/AED.¹⁸ The ILCOR review focused on 23 key topics leading to 32 Treatment Recommendations in the domains of early access and cardiac arrest prevention, early, high-quality CPR, and early defibrillation.

Cardiac arrest

Sudden cardiac arrest (SCA) is one of the leading causes of death in Europe. On initial heart-rhythm analysis, about 25–50% of SCA victims have ventricular fibrillation (VF)^{19, 20, and 21} but when the rhythm is recorded soon after collapse, in particular by an on-site AED, the proportion of victims in VF can be as high as 76%.^{22 and 23} The recommended treatment for VF cardiac arrest is immediate bystander CPR and early electrical defibrillation. Most cardiac arrests of non-cardiac origin have respiratory causes, such as drowning (among them many children) and asphyxia. Rescue breaths as well as chest compressions are critical for successful resuscitation of these victims.

The chain of survival

The Chain of Survival summarises the vital links needed for successful resuscitation ( Fig. 1.2 ). Most of these links apply to victims of both primary cardiac and asphyxial arrest.¹³

Fig. 1.2 The Chain of Survival.

1: Early recognition and call for help

Recognising the cardiac origin of chest pain, and calling the emergency services before a victim collapses, enables the emergency medical service to arrive sooner, hopefully before cardiac arrest has occurred, thus leading to better survival.^{24, 25, and 26}

Once cardiac arrest has occurred, early recognition is critical to enable rapid activation of the EMS and prompt initiation of bystander CPR. The key observations are unresponsiveness and not breathing normally.

2: Early bystander CPR

The immediate initiation of CPR can double or quadruple survival after cardiac arrest.^{27, 28, and 29} If able, bystanders with CPR training should give chest compressions together with ventilations. When a bystander has not been trained in CPR, the emergency medical dispatcher should instruct him or her to give chest-compression-only CPR while awaiting the arrival of professional help.^{30, 31, and 32}

3: Early defibrillation

Defibrillation within 3–5 min of collapse can produce survival rates as high as 50–70%. This can be achieved by public access and onsite AEDs.^{21, 23, and 33}

4: Early advanced life support and standardised post-resuscitation care

Advanced life support with airway management, drugs and correcting causal factors may be needed if initial attempts at resuscitation are un-successful.

The critical need for bystanders to act

In most communities, the median time from emergency call to emergency medical service arrival (response interval) is 5–8 min,^{22, 34, 35, and 36} or 8–11 min to a first shock.^{21 and 28} During this time the victim's survival depends on bystanders who initiate CPR and use an automated external defibrillator (AED).^{22 and 37}

Recognition of cardiac arrest

Recognising cardiac arrest can be challenging. Both bystanders and emergency call handlers (emergency medical dispatchers) have to diagnose cardiac arrest promptly in order to activate the chain of survival. Checking the carotid pulse (or any other pulse) has proved to be an inaccurate method for confirming the presence or absence of circulation.^{38, 39, 40, 41, and 42} Agonal breathing may be present in up to 40% of victims in the first minutes after cardiac arrest, and if responded to as a sign of cardiac arrest, is associated with higher survival rates.⁴³ The significance of agonal breathing should be emphasised during basic life support training.^{44 and 45} Bystanders should suspect cardiac arrest and start CPR if the victim is unresponsive and not breathing normally. Bystanders should be suspicious of cardiac arrest in any patient presenting with seizures.^{46 and 47}

Role of the emergency medical dispatcher

Dispatcher recognition of cardiac arrest

Patients who are unresponsive and not breathing normally should be presumed to be in cardiac arrest. Agonal breathing is often present, and callers may mistakenly believe the victim is still breathing normally.^{48, 49, 50, 51, 52, 53, 54, 55, 56, and 57} Offering dispatchers additional education, specifically addressing the identification and significance of agonal breathing, can improve cardiac arrest recognition, increase the provision of telephone-CPR,^{55 and 57} and reduce the number of missed cardiac arrest cases.⁵²

If the initial emergency call is for a person suffering seizures, the call taker should be highly suspicious of cardiac arrest, even if the caller reports that the victim has a prior history of epilepsy.^{49 and 58}

Dispatcher-assisted CPR

Bystander CPR rates are low in many communities. Dispatcher-assisted CPR (telephone-CPR) instructions improve bystander CPR rates,^{56, 59, 60, 61, and 62} reduce the time to first CPR,^{57, 59, 62, 63, and 64} increase the number of chest compressions delivered⁶⁰ and improve patient outcomes following out-of-hospital cardiac arrest (OHCA) in all patient groups.^{30, 31, 32, 56, 61, 63, and 65} Dispatchers should provide telephone-CPR instructions in all cases of suspected cardiac arrest unless a trained provider is already delivering CPR. Where instructions are required for an adult victim, dispatchers should provide chest-compression-only CPR instructions. If the victim is a child, dispatchers should instruct callers to provide both ventilations and chest compressions.

Adult BLS sequence

Fig. 1.3 presents the step-by-step sequence for the trained provider. It continues to highlight the importance of ensuring rescuer, victim and bystander safety. Calling for additional help (if required) is incorporated in the alerting emergency services step below. For clarity the algorithm is presented as a linear sequence of steps. It is recognised that the early steps of checking response, opening the airway, checking for breathing and calling the emergency medical dispatcher may be accomplished simultaneously or in rapid succession.

Fig. 1.3 The basic life support/automated external defibrillation (BLS/AED) algorithm.

Those who are not trained to recognise cardiac arrest and start CPR would not be aware of these guidelines and therefore require dispatcher assistance whenever they make the decision to call 112 ( Fig. 1.4 ).

Fig. 1.4 Step by step sequence of actions for use by the BLS/AED trained provider to treat the adult cardiac arrest victim.

Opening the airway and checking for breathing

The trained provider should assess the collapsed victim rapidly to determine if they are responsive and breathing normally. Open the airway using the head tilt and chin lift technique whilst assessing whether the person is breathing normally.

Alerting emergency services

112 is the European emergency phone number, available everywhere in the EU, free of charge. It is possible to call 112 from fixed and mobile phones to contact any emergency service: an ambulance, the fire brigade or the police. Early contact with the emergency services will facilitate dispatcher assistance in the recognition of cardiac arrest, telephone instruction on how to perform CPR, emergency medical service/first responder dispatch, and on locating and dispatching of an AED.^{66, 67, 68, and 69}

Starting chest compressions

In adults needing CPR, there is a high probability of a primary cardiac cause. When blood flow stops after cardiac arrest, the blood in the lungs and arterial system remains oxygenated for some minutes. To emphasise the priority of chest compressions, it is recommended that CPR should start with chest compressions rather than initial ventilations.

When providing manual chest compressions:

1. Deliver compressions ‘in the centre of the chest’
2. Compress to a depth of at least 5 cm but not more than 6 cm
3. Compress the chest at a rate of 100–120 min⁻¹ with as few interruptions as possible
4. Allow the chest to recoil completely after each compression; do not lean on the chest

Hand position

Experimental studies show better haemodynamic responses when chest compressions are performed on the lower half of the sternum.^{70, 71, and 72} It is recommended that this location be taught in a simplified way, such as, “place the heel of your hand in the centre of the chest with the other hand on top”. This instruction should be accompanied by a demonstration of placing the hands on the lower half of the sternum.^{73 and 74}

Chest compressions are most easily delivered by a single CPR provider kneeling by the side of the victim, as this facilitates movement between compressions and ventilations with minimal interruptions. Over-the-head CPR for single CPR providers and straddle-CPR for two CPR providers may be considered when it is not possible to perform compressions from the side, for example when the victim is in a confined space.^{75 and 76}

Compression depth

Data from four recent observational studies suggest that a compression depth range of 4.5–5.5 cm in adults leads to better outcomes than all other compression depths during manual CPR.^{77, 78, 79, and 80} One of these studies found that a compression depth of 46 mm was associated with the highest survival rate.⁷⁹ The ERC, therefore, endorses the ILCOR recommendation that it is reasonable to aim for a chest compression depth of approximately 5 cm but not more than 6 cm in the average sized adult.⁸¹ In line with the ILCOR recommendation, the ERC decided to retain the 2010 guidance to compress the chest at least 5 cm but not more than 6 cm.

Compression rate

Two studies found higher survival among patients who received chest compressions at a rate of 100–120 min⁻¹. Very high chest compression rates were associated with declining chest compression depths.^{82 and 83} The ERC recommends, therefore, that chest compressions should be performed at a rate of 100–120 min⁻¹.

Minimising pauses in chest compressions

Pre- and post-shock pauses of less than 10 s, and chest compression fractions >60% are associated with improved outcomes.^{84, 85, 86, 87, and 88} Pauses in chest compressions should be minimised.

Firm surface

CPR should be performed on a firm surface whenever possible. Air-filled mattresses should be routinely deflated during CPR.⁸⁹ The evidence for the use of backboards is equivocal.^{90, 91, 92, 93, and 94} If a backboard is used, take care to avoid interrupting CPR and dislodging intravenous lines or other tubes during board placement.

Chest wall recoil

Allowing complete recoil of the chest after each compression results in better venous return to the chest and may improve the effectiveness of CPR.^{95, 96, 97, and 98} CPR providers should, therefore, take care to avoid leaning after each chest compression.

Duty cycle

There is very little evidence to recommend any specific duty cycle and, therefore, insufficient new evidence to prompt a change from the currently recommended ratio of 50%.

Feedback on compression technique

None of the studies on feedback or prompt devices has demonstrated improved survival to discharge with feedback.⁹⁹ The use of CPR feedback or prompt devices during CPR should only be considered as part of a broader system of care that should include comprehensive CPR quality improvement initiatives,^{99 and 100} rather than as an isolated intervention.

Rescue breaths

We suggest that during adult CPR tidal volumes of approximately 500–600 ml (6–7 ml kg⁻¹) are delivered. Practically, this is the volume required to cause the chest to rise visibly.¹⁰¹ CPR providers should aim for an inflation duration of about 1 s, with enough volume to make the victim's chest rise, but avoid rapid or forceful breaths. The maximum interruption in chest compression to give two breaths should not exceed 10 s.¹⁰²

Compression–ventilation ratio

A ratio of 30:2 was recommended in ERC Guidelines 2010 for the single CPR provider attempting resuscitation of an adult. Several observational studies have reported slightly improved outcomes after implementation of the guideline changes, which included switching from a compression ventilation ratio of 15:2 to 30:2.^{103, 104, 105, and 106} The ERC continues, therefore, to recommend a compression to ventilation ratio of 30:2.

Compression-only CPR

Observational studies, classified mostly as very low-quality evidence, have suggested equivalence of chest-compression-only CPR and chest compressions combined with rescue breaths in adults with a suspected cardiac cause for their cardiac arrest.^{27, 107, 108, 109, 110, 111, 112, 113, 114, 115, 116, 117, and 118} Our confidence in the equivalence between chest-compression-only and standard CPR is not sufficient to change current practice. The ERC, therefore, endorses the ILCOR recommendations that all CPR providers should perform chest compressions for all patients in cardiac arrest. CPR providers trained and able to perform rescue breaths should perform chest compressions and rescue breaths as this may provide additional benefit for children and those who sustain an asphyxial cardiac arrest^{111, 119, and 120} or where the EMS response interval is prolonged.¹¹⁵

Use of an automated external defibrillator

AEDs are safe and effective when used by laypeople with minimal or no training.¹²¹ AEDs make it possible to defibrillate many minutes before professional help arrives. CPR providers should continue CPR with minimal interruption of chest compressions while attaching an AED and during its use. CPR providers should concentrate on following the voice prompts immediately when they are spoken, in particular resuming CPR as soon as instructed, and minimising interruptions in chest compression. Standard AEDs are suitable for use in children older than 8 years.^{122, 123, and 124} For children between 1 and 8 years use paediatric pads, together with an attenuator or a paediatric mode if available.

CPR before defibrillation

Continue CPR while a defibrillator or AED is being brought on-site and applied, but defibrillation should not be delayed any longer.

Interval between rhythm checks

Pause chest compressions every 2 min to assess the cardiac rhythm.

Voice prompts

It is critically important that CPR providers pay attention to AED voice prompts and follow them without any delay. Voice prompts are usually programmable, and it is recommended that they be set in accordance with the sequence of shocks and timings for CPR given above. Devices measuring CPR quality may in addition provide real-time CPR feedback and supplemental voice/visual prompts.

In practice, AEDs are used mostly by trained rescuers, where the default setting of AED prompts should be for a compression to ventilation ratio of 30:2. If (in an exception) AEDs are placed in a setting where such trained rescuers are unlikely to be available or present, the owner or distributor may choose to change the settings to compression only.

Public access defibrillation (PAD) programmes

Placement of AEDs in areas where one cardiac arrest per 5 years can be expected is considered cost-effective and comparable to other medical interventions.^{125, 126, and 127} Registration of AEDs for public access, so that dispatchers can direct CPR providers to a nearby AED, may also help to optimise response.¹²⁸ The effectiveness of AED use for victims at home is limited.¹²⁹ The proportion of patients found in VF is lower at home than in public places, however the absolute number of potentially treatable patients is higher at home.¹²⁹ Public access defibrillation (PAD) rarely reaches victims at home.¹³⁰ Dispatched lay CPR providers, local to the victim and directed to a nearby AED, may improve bystander CPR rates³³ and help reduce the time to defibrillation.³⁷

Universal AED signage

ILCOR has designed a simple and clear AED sign that may be recognised worldwide and this is recommended to indicate the location of an AED.¹³¹

In-hospital use of AEDs

There are no published randomised trials comparing in-hospital use of AEDs with manual defibrillators. Three observational studies showed no improvements in survival to hospital discharge for in-hospital adult cardiac arrest when using an AED compared with manual defibrillation.^{132, 133, and 134} Another large observational study showed that in-hospital AED use was associated with a lower survival-to-discharge rate compared with no AED use.¹³⁵ This suggests that AEDs may cause harmful delays in starting CPR, or interruptions in chest compressions in patients with non-shockable rhythms.¹³⁶ We recommend the use of AEDs in those areas of the hospital where there is a risk of delayed defibrillation,¹³⁷ because it will take several minutes for a resuscitation team to arrive, and first responders do not have skills in manual defibrillation. The goal is to attempt defibrillation within 3 min of collapse. In hospital areas where there is rapid access to manual defibrillation, either from trained staff or a resuscitation team, manual defibrillation should be used in preference to an AED. Hospitals should monitor collapse-to-first shock intervals and audit resuscitation outcomes.

Risks to the CPR provider and recipients of CPR

In victims who are eventually found not to be in cardiac arrest, bystander CPR extremely rarely leads to serious harm. CPR providers should not, therefore, be reluctant to initiate CPR because of concern of causing harm.

Foreign body airway obstruction (choking)

Foreign body airway obstruction (FBAO) is an uncommon but potentially treatable cause of accidental death.¹³⁸ As victims initially are conscious and responsive, there are often opportunities for early interventions which can be life saving.

Recognition

FBAO usually occurs while the victim is eating or drinking. Fig. 1.5 presents the treatment algorithm for the adult with FBAO. Foreign bodies may cause either mild or severe airway obstruction. It is important to ask the conscious victim “Are you choking?”. The victim that is able to speak, cough and breathe has mild obstruction. The victim that is unable to speak, has a weakening cough, is struggling or unable to breathe, has severe airway obstruction.

Fig. 1.5 Step by step sequence of actions for the treatment of the adult victim with foreign body airway obstruction.

Treatment for mild airway obstruction

Encourage the victim to cough as coughing generates high and sustained airway pressures and may expel the foreign body.

Treatment for severe airway obstruction

For conscious adults and children over one year of age with complete FBAO, case reports have demonstrated the effectiveness of back blows or ‘slaps’, abdominal thrusts and chest thrusts.¹³⁹ The likelihood of success is increased when combinations of back blows or slaps, and abdominal and chest thrusts are used.¹³⁹

Treatment of foreign body airway obstruction in an unresponsive victim

A randomised trial in cadavers¹⁴⁰ and two prospective studies in anaesthetised volunteers^{141 and 142} showed that higher airway pressures can be generated using chest thrusts compared with abdominal thrusts. Chest compressions should, therefore, be started promptly if the victim becomes unresponsive or unconscious. After 30 compressions attempt 2 rescue breaths, and continue CPR until the victim recovers and starts to breathe normally.

Victims with a persistent cough, difficulty swallowing or the sensation of an object being still stuck in the throat should be referred for a medical opinion. Abdominal thrusts and chest compressions can potentially cause serious internal injuries and all victims successfully treated with these measures should be examined afterwards for injury.

Resuscitation of children (see also section 6) and victims of drowning (see also section 4)

Many children do not receive resuscitation because potential CPR providers fear causing harm if they are not specifically trained in resuscitation for children. This fear is unfounded: it is far better to use the adult BLS sequence for resuscitation of a child than to do nothing. For ease of teaching and retention, laypeople should be taught that the adult sequence may also be used for children who are not responsive and not breathing normally. The following minor modifications to the adult sequence will make it even more suitable for use in children:

Give 5 initial rescue breaths before starting chest compressions
Give CPR for 1 min before going for help in the unlikely event the CPR provider is alone
Compress the chest by at least one third of its depth; use 2 fingers for an infant under one year; use 1 or 2 hands for a child over 1 year as needed to achieve an adequate depth of compression

The same modifications of 5 initial breaths and 1 min of CPR by the lone CPR provider before getting help, may improve outcome for victims of drowning. This modification should be taught only to those who have a specific duty of care to potential drowning victims (e.g. lifeguards).