Journal of Emergencies, Trauma, and Shock
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Year : 2012  |  Volume : 5  |  Issue : 1  |  Page : 1-2
What's new in Emergencies, Trauma and Shock? Resuscitation guidelines update in 2010: Implications for bystander CPR

Director, Public Health Solutions Pakistan, Lahore, Pakistan

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Date of Submission18-Sep-2011
Date of Acceptance14-Oct-2011
Date of Web Publication22-Feb-2012

How to cite this article:
Waseem H. What's new in Emergencies, Trauma and Shock? Resuscitation guidelines update in 2010: Implications for bystander CPR. J Emerg Trauma Shock 2012;5:1-2

How to cite this URL:
Waseem H. What's new in Emergencies, Trauma and Shock? Resuscitation guidelines update in 2010: Implications for bystander CPR. J Emerg Trauma Shock [serial online] 2012 [cited 2022 Sep 26];5:1-2. Available from:

One of the fundamental issues identified by Education, Implementation and Teams (EIT) task force of International Liaison Committee on Resuscitation during the Guidelines 2010 evidence evaluation process was the training of all citizens in standard cardiopulmonary resuscitation (CPR) that includes both compressions and ventilations. [1] The "Chain of survival" comprises of actions which can link the victims of a cardiac arrest to possible survival. The four actions as described in the 2010 guidelines are:

  1. Recognizing early cardiac arrest and calling for help - to prevent cardiac arrest.
  2. Immediate CPR - to buy time
  3. Early Defibrillation - to restart the heart
  4. Post-resuscitation care - to restore quality of life. [1]

The average time from ambulance call to ambulance arrival (response interval) in most healthcare systems is 5-8 minutes, [2] in case of an out of hospital cardiac arrest. Since three out of four of the above mentioned actions may take place in the pre-hospital environment, therefore the role of bystanders assumes significant importance as the victim of a cardiac arrest becomes dependent on them for basic life support and defibrillation. It has been established in numerous studies that bystander CPR and early defibrillation can save lives. Bystander CPR alone doubles or triples survival from witnessed cardiac arrest. [3]

However, many factors hamper the willingness of bystanders to start CPR, including panic, fear of disease transmission, harming the victim, harming oneself or performing CPR incorrectly. [4],[5] Some other apprehensions that exist in first responders are whether they can accurately recognize cardiac arrest as well as giving rescue breaths to unknown victims. [4],[5] Within the medical community too, certain misgivings subsist regarding effectiveness and appropriateness of bystander CPR.

In this issue of JETS, an original research article explores in detail the complications associated with bystander CPR in a population, which was later proved to be unconscious rather than having a cardiac arrest. The purpose of this research was to explore the safety of bystander CPR in patients who may not be in cardiac arrest, as a way to encourage ordinary people to become more proactive in initiating CPR. This study which was a population-based observational case series in a tertiary care facility found a very low rate of complications; only 11.5% (3 cases out of 26) in patients who were not in cardiac arrest but received CPR out of hospital. The complications included a tracheal bleeding, one gastric mucosal laceration. and one minor rib fracture. It is worth noting that some complications may have been missed in this study because no additional investigations were undertaken to seek more sequels. Certain other limitations that exist in this study are the fact that till the emergency medical services (EMS) contact, there is no way of confirming whether the victims were really in a cardiac arrest or not. Possibility exists that by the time the EMS arrived, the patients had reverted to spontaneous circulation. In my view, the sample size studied is too small to be of huge significance in the field of resuscitation but it is a start nevertheless and the authors deserve appreciation for bringing forth data which can form important evidence in supporting and encouraging bystander CPR in future. Scarce medical literature exists up till now regarding complications of bystander CPR in case of non-cardiac arrest and therefore this work is of significant importance. Further research needs to be undertaken on this subject to further promote the safety of CPR by first responders and to encourage lay population to initiate CPR even in cases when they are not sure about cardiac arrest.

A review of literature reveals that complications of bystander CPR to victims have been previously well-documented with the most frequently reported being skeletal injuries and injuries of the gastrointestinal (lacerations, ruptures, hemorrhage) and cardiopulmonary systems (lacerations, hemorrhage, pneumohemothorax, pneumomediastinum, and myocardial or tracheal rupture). [5] These studies are based on autopsy findings in non-surviving cardiac arrest patients. In one study conducted by Oschatz et al, [6] a review of a single chest X-ray did not reveal any significant complications associated with bystander CPR as compared to expert CPR. In another study of dispatch-assisted CPR, by White et al where non-arrest victims received bystander CPR, 12% experienced discomfort but only 2% suffered a fracture and no victims suffered visceral organ injury. The low rate of complications in these studies is in concordance with the findings of the paper published in this issue of JETS.

This particular research paper assumes additional significance in the aftermath of the updated resuscitation guidelines of 2010, which has laid strong emphasis on bystander CPR and has described strategies to prevent the delay in the initiation of CPR and to enhance the quality of first responder CPR.

One of the first changes in the updated resuscitation guidelines 2010 proposed is related to dispatcher training. Strict protocols should be established for interrogation of callers to draw information regarding recognition of unresponsiveness and quality of breathing. Gasping as a sign of cardiac arrest is emphasized and a combination of unresponsiveness and abnormal breathing should be enough to initiate a dispatch protocol of cardiac arrest. Furthermore, bystanders whether trained or not should be able to provide chest compressions to victims. Good quality chest compressions of appropriate depth and rate of atleast 100/min are re-emphasized.

To further encourage non-healthcare professionals to start CPR, palpation of carotid pulse has been completely abolished and the presence of agonal breathing or gasping is deemed to be a good enough indication of starting CPR immediately. [7] The old sequence of checking for foreign bodies and giving two rescue breaths as described in 2005 has been modified to exclude the oral cavity check and instead of wasting time in two rescue breaths, responders should immediately go to CPR in order to minimize the delay in starting chest compressions. Some healthcare professionals and first responders alike have shown a reluctance to perform mouth-to-mouth ventilation in unknown victims of cardiac arrest. The new guideline suggests that lay people should be encouraged to perform compression-only CPR if they are unable or unwilling to provide rescue breaths, or when instructed during an emergency call to an ambulance dispatcher centre.

According to the new European resuscitation guideline providing CPR training to lay people will increase their willingness to perform CPR. An effective substitute of instructor led BLS courses can be short video/computer self-instruction courses with hands-on practice. Frequent skills assessments should be undertaken and refresher training imparted in individuals requiring them. CPR prompt or feedback devices improve CPR skill acquisition and should be considered during CPR training. [6]

   References Top

1.Koster RW, Baubin MA, Bossaert LL, Caballero A, Cassan P, Castrén M, et al. European Resuscitation Council Guidelines for Resuscitation 2010. Section 2. Adult basic life support and useof automated external defibrillators. Resuscitation 2010;81:1277-92.  Back to cited text no. 1
2.Weisfeldt ML, Sitlani CM, Ornato JP, Rea T, Aufderheide TP, Davis D, et al. Survival after application of automatic external defibrillators before arrival of the emergency medical system: Evaluation in the resuscitation outcomes consortium population of 21 million. J Am Coll Cardiol 2010;55:1713-20.  Back to cited text no. 2
3.Larsen MP, Eisenberg MS, Cummins RO, Hallstrom AP. Predicting survival from out-of-hospital cardiac arrest: Agraphic model. Ann Emerg Med 1993;22:1652-8.  Back to cited text no. 3
4.Coons SJ, Guy MC. Performing bystander CPR for sudden cardiac arrest: Behavioral intentions among the general adult population in Arizona. Resuscitation 2009;80:334-40.  Back to cited text no. 4
5.Johnston TC, Clark MJ, Dingle GA, FitzGerald G. Factors influencing Queenslanders' willingness to perform bystander cardiopulmonary resuscitation. Resuscitation 2003;56:67-75.  Back to cited text no. 5
6.Oschatz E, Wunderbaldinger P, Sterz F, Holzer M, Kofler J, Slatin H, et al. Cardiopulmonary resuscitation performed by bystanders does not increase adverse effects as assessed by chest radiography.AnesthAnalg 2001;93:128-33.  Back to cited text no. 6
7.Nolan JP, Soar J, Zideman DA, Biarent D, Bossaert LL, Deakin C, et al.European Resuscitation Council Guidelines for Resuscitation 2010 Section 1. Executive summary. Resuscitation 2010;81:1219-76.  Back to cited text no. 7

Correspondence Address:
Hunniya Waseem
Director, Public Health Solutions Pakistan, Lahore
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0974-2700.93092

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