Introduction
Basic Life Support (BLS) is an internationally recognised protocol designed to be taught to all hospital staff members and to members of the general public. The most recent guidelines were published in 2015 (1). BLS courses are run by medical institutions (usually hospitals) – often as a 1-2 hour course. Most medical institutions require all staff (including non-clinical staff) to regularly – usually annually – attend the course.
BLS is designed to be performed without any equipment (or an automated defibrillator if one is available).
It is a technique used to try and keep a patient alive until proper equipment can be brought to try and reverse the underlying cardiac arrest.
Rarely, CPR can be enough to reverse an underlying cardiac arrest, most commonly when it is secondary to a respiratory arrest (e.g. drowning).
If the oxygen supply to the brain is lost for more than 3-4 minutes then permanent cerebral damage will result (this time may be much long in cold situations – such as a person falling into a frozen body of water). Therefore, prompt initiation and continuation of BLS are paramount for a good outcome.
When faced with a situation where BLS is used – don’t be afraid to try your best – any attempt is better than no attempt at all.
For every delay of one minute for defibrillation the chance of survival is reduced by 10%.
The Basic Principle
The basic principle is very simple and can be summarised with the flowchart below. From (1)
Method
You can use the acronym DRS-ABCD to remember the steps:
D – Danger
- This is to ensure your safety and that of other bystanders
- Use personal protective equipment (PPE) where approrpiate
- Dangers might include; trips and spill hazards, electrical cords, sharps, vehicles, bystanders
R – Responsiveness
- Check the patient for a response
- Tap the patient on the shoulder and give a basic instruction – such as “squeeze my fingers” or “open your eyes”
- This is sometimes called “tap and talk“
S – Send for help
A – Airway
B – Breathing
C – CPR
D – Defibrillator (if available)
- Adult chest pads should only be used on a patient who is >25kgs and at least 8 years of age
You see a collapsed patient…
- Check for danger! Make sure the situation is safe before approaching
- Check for a response – shake the victim’s shoulders and ask loudly if they are ok. If they respond, then you should leave them where they are, provided they are not in danger. Try and find out what is wrong then go and get help. Return to the patient as soon as you can and keep re-assessing them.
- If they do not respond, then:
- Shout for Help! If no help is available, go and get help (e.g. call emergency services, or go to find somebody else to do this for you).
- Open the patient’s airway, by doing the head tilt and chin lift.
- Listen for normal breathing and look to see if you can see the patient’s chest rising and falling. Can you feel breath on your cheek? Do this for no more than 10 seconds. Don’t confuse gasping irregular breaths (“agonal breathing” – which are often associated with cardiac arrest) with normal breathing. If you have any doubts about normal breathing, then assume the patient is not breathing normally.
- If they are breathing normally, put them into the: Recovery position – Imagine the patient lying flat on their back. Lift up their left knee and put the outside of their left hand against their right cheek. Roll the patient onto their right hand side, making sure their hand is in contact with their cheek at all times. Their right arm should be stretched out at 90’ to their torso. Do not keep the person laid on one side for more than 30 minutes due to the pressure on their arm. Swap them over to the other side before then.
- When you return, you should start chest compressions. You should kneel on the patient’s right hand side. Put your hand in the middle of the patient’s chest, about 2 fingers above the level of the bottom of the sternum. Interlock your fingers. Don’t apply pressure on the stomach or on the very bottom of the sternum! Position yourself so you are vertically over the patient’s chest and keep you arms straight. Press down about 5-6cm (1/3 of the depth of the chest). You should aim to do 100 compressions a minute, or about 2 per second. Some recommend imagining the pace of a song in your head… and performing chest compressions to the ‘beat’. Apparently two appropriately speedy songs are:
- Staying Alive – The BeeGees
- Nelly the Elephant – The Nursery Rhyme
- Often, suitably hard chest compressions will cause rib fractures. You might hear the ribs cracking – don’t worry!
- After 30 compressions, open the airway again, doing the head tilt and chin lift. Pinch the nose closed, and whilst still maintaining the chin lift and keeping the mouth open, take a normal breath and give two breaths to the patient. Breathe out for about 1 second. You should see the patient’s chest rise. If not, the its likely the air is going into the stomach, and you are not correctly holding the patient’s head in the ‘head tilt, chin lift’ position. Allow the air to come out of the patient and then do the same again. You should maintain the chin lift at all times. After this start 30 compressions again. Don’t ever attempt more than 2 breaths. If the chest doesn’t rise, then check for obstructions. If there is more than one person present, you should swap over about every 2 minutes to prevent fatigue. You should continue resuscitation until help arrives, or until the victim recovers, or until you can no longer continue because you are exhausted.
- Often in a hospital setting breaths will be provided by BVM – Bag, valve and mask ventilation.
- If an automated defibrillator is available, then attach the pads to the patient’s chest. If you have help, ask someone to do this for you whilst you continue CPR.
- Follow the audible instructions
- Make sure nobody is touching the patient when a shock is delivered (if one is delivered)
- Immediately resume CPR and continue to follow the audible instructions
- Continue CPR until:
- The patient recovers (rare) – if you are unsure whether or not they have recovered, then continue CPR
- You are exhausted
- Further help arrives (e.g. ambulance, or, in hospital, the crash team)
Exceptions
The guidelines for children are different.
- Give 5 rescue breaths first
- Recommended in BLS 2015 guidelines but no longer in Australia guidelines in 2023
- Consider giving chest compressions and breaths in the ratio 15:2
- As of 2023 the Australia resuscitation council now recommends to give 30:2 – the same ratio as adults
- The head position for infants is neutral (due to their bigger relative head size), and for older child is the “sniff” position
- Chest compressions for an infant should be performed with two fingers and to a chest depth of 1/3 of the chest
- Chest compressions for a child should also be for 1/3 the depth of the chest and can be performed with one or two hands
- The location of compressions is the same as an adult – the lower half of the sternum
Children are more likely to have suffered a primary respiratory arrest than adults. As a result, you can consider giving 5 rescue breaths before starting chest compressions, and you should attempt CPR for 1 minute before going for help.
These same exceptions may be applied if the victim is suspected of drowning.
For pregnant women (in those who appear >20 weeks gestation) it is advised to raised the right hip off the ground by 15-30 degrees – either using a wedge (if you are in hospital and one is available) or a rolled up towel or other piece of clothing. This is to take the weight of the foetus off of the vena cava to improve venous return to the heart.
References
Adult basic life support and automated external defibrillation. Resuscitation Council (UK). 2015
Accessed online on 13th Feb 2018. Available here