On May 6 2021, the Resuscitation Council UK (RCUK) issued brand new guidelines for basic life support (BLS).(1) These guidelines are updated every five years and are based on the latest research and evidence available to ensure healthcare professionals can provide the best care possible and improve survival rates from cardiac arrest.
When guidelines change, it can be a challenge to ensure we stay up to date, but the focus of these new guidelines is to increase confidence, knowledge and skills to act when someone suffers a cardiac arrest. To help with continuity, there are no major changes in BLS in these new guidelines.
In the UK, resuscitation is attempted outside of hospital on approximately 30,000 people each year.(1) What would happen if one of these patients collapsed in your pharmacy? Could one of these patients be the customer popping in for some indigestion tablets thinking their chest pain is all down to the curry last night? Or perhaps the customer hoping you will be able to help as she forgot her inhaler and is struggling to breathe? Maybe it is the vulnerable patient outside who has taken too many tablets in a bid to end their own life.
Cardiac arrest associated with vaccinations
Cardiac arrests are primarily caused by ischaemic heart disease in 62% of all cases.(2) However, there has understandably been a high level of anxiety from pharmacists undertaking vaccination training about cardiac arrest occurring, especially post vaccination, caused by anaphylaxis. This anxiety has been especially noticeable during the COVID-19 vaccine roll-out.(3)
The role of the pharmacy team
In the UK, seven out of 10 cases of cardiac arrest will see bystanders attempt resuscitation.(1) However, the reality is that survival rates remain very low (9%) for out-of-hospital cardiac arrests. Nevertheless, there are some very simple things to that can be tried to improve this outcome.(1) The Chain of Survival is a sequence of steps that, when completed together, maximises the patient’s chance of survival. The four steps include:
- Immediate recognition of cardiac arrest and calling for help
- Prompt initiation of cardiopulmonary resuscitation (CPR)
- Performing defibrillation as soon as possible
- Optimal post resuscitation care
This chain can only remain strong when bystanders perform CPR and an Automatic External Defibrillator (AED) is used prior to an ambulance arriving. When all of these key parts are implemented together, survival rates of in excess of 50% have been known.(4)
Resuscitation is a core skill within first aid and this is one of the requirements of pre-registration training. The General Pharmaceutical Council (GPhC) states: “The public expects a pharmacist to be able to help if there is an accident or emergency near the pharmacy or in the pharmacy itself.”(5) So, while there is a recognition that it may not be the pharmacist who is a designated first aider, there is a clear expectation that the pharmacist would be able to help. Further to this, there are commissioned services within pharmacy that stipulate the requirement for resuscitation training, such as the provision of NHS or private vaccination services, including flu, travel and, of course, the current COVID-19 vaccinations.(6)
Basic Life Support Instructions
The steps involved in CPR include:(1)
Safety: The first priority is to ensure the safety of yourself and others around you. This is often overlooked and is easy to do so in the instinctive reaction to help, but the responder could find themselves in a very dangerous position if they don’t stop and pause. It is important to have a look around the environment and look for potential dangers eg has a sharps bin been knocked over? Is there an electric cable attached to the patient? If the environment can be made safe, then this should be done first. However, if it is not safe for the responder to proceed, it is important to withdraw and call the emergency services.
Response: Once it is safe to proceed, the responder should try to get some response from the patient. The responder should talk or shout to patient to try and get a response and failing that, they can give them a gentle shake on the shoulders while asking, “Are you alright?”.
Airway: If there was no response from the patient, it is important to open the patient’s airway. Placing them on their back, a hand should be placed on their forehead and fingers placed under their chin, gently tilting their head backwards, lifting the chin to open the airway. This manoeuvre opens the airway because it causes the tongue to move away from the back of the mouth, which could be blocking the patient's airway.
Breathing: Only once the airway is open should the responder move on to check if the patient is breathing. The responder should look, listen and feel for no more than 10 seconds. Look along the line of the chest to see if the chest is rising. Listen to hear any breath sounds and feel for breaths on the side of your cheek. Slow, laboured breathing (also known as agonal breathing) should be considered a cardiac arrest. If the patient is breathing normally, they should be placed in the recovery position in order to protect their airway.
Call for help: If the patient is not breathing, it is important to call for help. The responder should stay with the patient and send someone to call 999 and advise the emergency services that there is an “unconscious patient who is not breathing”.
AED: At this stage, the responder should consider if there is an AED nearby and send someone to collect it. If the responder is on their own, it is important not to leave the patient alone, and CPR should be started.
Chest compressions: Without delay, the responder should start chest compressions. The responder should kneel to the side of the patient, place the heel of one hand in the centre of the patient’s chest and place the other hand on top and interlock fingers. Keeping their arms straight, the responder should press down on the chest between 5-6cm and then release the pressure again, keeping hands in contact with the patient’s chest throughout. This should be repeated to give a total of 30 chest compressions, using a rate of 100-120 per minute (almost two compressions per second).
Rescue breaths: Once 30 compressions have been given, rescue breaths should be given. If a pocket mask is available in the pharmacy, this should be removed from its case and placed over the patient’s face, covering their nose and mouth. Pressing firmly against the face to make a seal, the head should be tilted back to ensure the airway remains open and the responder should gently blow into the one-way valve over one second. The chest should rise and the responder should take a normal breath whilst the chest falls and then give a second rescue breath.
If a pocket mask is not available, the responder should consider giving mouth to mouth. To do this, open the airway by performing a “head-tilt-chin-lift” again, pinch the patient’s nose and using their own mouth, the responder should make a good seal around the patient’s mouth before giving breaths. If the responder is unable to give mouth to mouth (perhaps due to blood or vomit around the mouth), then the responder can continue to give continuous chest compressions only (at a rate of 100-120 per minute). Assuming rescue breaths have been given, return immediately to the chest to give a further 30 compressions and then continue to alternate at a ratio of 30 compressions to two breaths.
Guidelines on the management of cardiac arrest in patients with known or suspected COVID-19 can be found here.
Cardiac arrest in children
When it comes to children, the aetiology of cardiac arrest differs. In adults, the primary cause is cardiac problems, however, in children, it is normally secondary to other causes, particularly a lack of oxygen within the body. With this in mind, there are three modifications to the adult sequence of BLS in order to accommodate this. The RCUK states that the modifications are:(7)
- Give five initial rescue breaths before starting chest compressions. If the responder is are alone and has mobile phone, call for help before starting compressions.
- If the responder is on their own without a mobile phone, perform CPR for one minute before going for help.
- Compress the chest by at least one-third of its depth, approximately 4cm for an infant and approximately 5cm for an older child. The responder should use both thumbs or two fingers for an infant under one year; and use one or two hands for a child over one year as required to achieve an adequate depth of compression.
- For all children, compressions and breaths should be continued in a ratio of 15 compressions to two breaths.
In order to maintain skills in resuscitation, it is important for pharmacist and pharmacy team members to undergo regular training. The RCUK recommends training should be renewed yearly.(4) Most BLS courses involve face-to-face training. This allows an experienced trainer to update their knowledge on the current guidelines, demonstrate the techniques and, importantly, allow the participant to have some hands on practice to help consolidate their learning. As with most things in life, since COVID-19 has affected our world, the options for undertaking this training have expanded to include a digital option and some pharmacists may find online learning or webinar based training to be a perferable option. The RCUK does not accredit BLS training courses, so options for these courses can be found from a variety of sources including voluntary organisations including St John’s Ambulance or The Red Cross, as well as other independent training providers.
ECG’s top tips for BLS
Sophie McCracken, paramedic and clinical director for ECG Training, shares some top tips from years of clinical experience, for when it comes to putting your BLS training into action:
- When calling 999, the first questions will always be, “what is the number you are calling from” and, “what is the address of the emergency?”. Would you be able to recall this information from your pharmacy instantly with such an incident ongoing? Have you got locum staff working who are less familiar with your details? It is advisable to have this information clearly marked next to your phone for use in an emergency, as a quick reference guide.
- Don’t be afraid to get stuck in. It is easy to assume there is someone else who has more knowledge when it comes to resuscitating someone. The key is not to delay starting chest compressions.
- CPR should be a team approach. When delivering chest compressions, you will tire quickly. The RCUK recommends swapping rescuers every two minutes in order to avoid fatigue as this will keep chest compressions at a high quality.(1)
- Send a team member outside to flag down the ambulance. The ambulance will be guided to the scene. Having someone outside clearly identifying where to go can be vital in saving seconds.
- Know where your closest AED is and don’t hesitate to use it. They are designed to be used by anyone, even if you have never used one before. Turn it on and listen to the instructions it will give you, it will guide you through everything you need to do. Rest assured, it makes all the decisions for you and it will not deliver a shock to a patient who doesn’t need it – they are incredibly safe.
The most important take home message when it comes to BLS is that something is better than nothing. Remember that if a patient suffers a cardiac arrest and no one attempts resuscitation, the patient will in all likelihood die. If you try; if you give chest compressions; if you do the best you can; you might just save their life.
This article was peer reviewed by Kate McComiskey, pharmacist.
- Resusciation Council UK (2021) Resuscitation guidelines
- National Institute of health and Care Excellence (2018) Cardiac arrest - out of hospital care: What causes it?
- Gov.UK (2021) Coronavirus vaccine - weekly summary of Yellow Card reporting
- Resusciation Council UK (2021) FAQs: Basic Life Support (CPR)
- General Pharmaceutical Council (2021) Medicines and health
- Public Health England (2018) National minimum standards and core curriculum for immunisation training for registered healthcare practitioners
- Resusciation Council UK (2021) Paediatric basic life support guidelines