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25

An overview of the new

resuscitation guidelines

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clinical practice

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author Phil Jevon, PGCE, BSc, RN, is resuscitation

officer/clinical skills lead, Manor Hospital, Walsall.
abstract Jevon, P. (2006) An overview of the
new resuscitation guidelines. Nursing Times; 102:
3, 2527.
New resuscitation guidelines contain significant
changes intended to improve resuscitation practice
and survival from cardiac arrest. The guidelines
also include helpful new sections with guidance on
in-hospital resuscitation. This article provides an
overview of the key changes and discusses their
practice implications for nurses.

The first international resuscitation guidelines

were published in 2000. This followed global
collaboration led by the International Liaison
Committee on Resuscitation to improve the practice
and teaching of resuscitation (Colquhoun and Nolan,
2005). The ILCOR 2005 formed the basis for the
European Resuscitation Council guidelines (European
Resuscitation Council, 2005). The Resuscitation
Council (UK) has issued an abbreviated version of
these guidelines (Resuscitation Council (UK), 2005a).

tachycardia or hypotension prior to collapse.

Unfortunately, ill patients at risk of cardiorespiratory
arrest are rarely identified, and those that are, are
often inappropriately managed (Kause et al, 2004).

Confirmation of cardiorespiratory arrest

Confirmation of cardiorespiratory arrest is not
straightforward. Undertaking a carotid pulse check is
an unreliable method of confirming the presence or
absence of circulation (Bahr et al, 1997). In addition,
there is no evidence that checking for movement,
breathing or coughing, as previously recommended,
is diagnostically superior. Agonal gasps and slow,
laboured or noisy breathing are common at the
onset of an arrest (Soar and Spearpoint, 2005) and
can be mistaken for adequate breathing.
To confirm cardiorespiratory arrest, look, listen,
and feel for signs of breathing for up to 10 seconds
to determine the absence of normal breathing. In
addition, those experienced in clinical assessment
may wish to check for the carotid pulse for up to 10
seconds either simultaneously or after checking for
breathing to determine its absence (Soar and
Spearpoint, 2005).

The key changes

Chain of survival
The Chain of Survival (Fig 1, p27), which describes
the actions linking a patient who has a cardiac arrest
with survival, has been revised to reflect the
emphasis of the European guidelines (Nolan, 2005).
Prevention of in-hospital cardiac arrest
There is particular emphasis on the importance of
prevention of in-hospital cardiac arrest. Most
patients who suffer a cardiac arrest in hospital
display adverse signs such as tachypnoea,

NT 17 January 2006 Vol 102 No 3 www.nursingtimes.net

Chest compressions
The main focus of the new guidelines is on chest
compressions, particularly on optimal performance
and minimising interruptions. Chest compression
technique is often poor with unnecessary and
lengthy interruptions (Abella et al, 2005). After a
break it takes several compressions to reach the
prestoppage coronary perfusion pressure (Kern et al,
1998). The new guidelines recommend:
l Using a ratio of 30 compressions to two
ventilations. In most situations the initial two

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References
Abella, B. et al (2005) Chest
compression rates during
cardiopulmonary resuscitation are
suboptimal: a prospective study
during inhospital cardiac arrest.
Circulation; 111: 428434.
Bahr, J. et al (1997) Skills of lay
people in checking the carotid pulse.
Resuscitation; 35: 2326.
Bingham, R. et al (2005) Paediatric
Basic life Support in Resuscitation
Guidelines 2005. Resuscitation
Council UK: London.
Chamberlain, D. (2005) New
international consensus
on cardiopulmonary resuscitation.
British Medical Journal;
331: 12811282.
Colquhoun, M., Nolan, J. (2005)
Introduction in Resuscitation
Guidelines 2005. London:
Resuscitation Council UK.
Davies, S. (2005) The Use of
Automated External Defibrillators
in Resuscitation Guidelines 2005.
London: Resuscitation Council UK.
Deakin, C. et al (2005) Adult
Advanced Life Support in
Resuscitation Guidelines 2005.
London: Resuscitation Council UK.
European Resuscitation Council
(2005) European Resuscitation
Council guidelines for
resuscitation. Resuscitation; 67:
(Suppl 1), S1S190.
Handley, A. (2005) Adult Basic
Life Support in Resuscitation
Guidelines 2005. London:
Resuscitation Council UK.

This article has been double-blind

peer-reviewed.
For related articles on this subject
and links to relevant websites see
www.nursingtimes.net

26

ventilations are omitted (except in the situations

discussed below) to allow more time for chest
compressions;
l Locate the correct position for compressions
by placing one hand in the centre of the chest and
the other on top, rather than wasting time using
the rib margin location method. Avoid applying
pressure over the end of the sternum and the
upper abdomen;
l To prevent fatigue, rotate the person performing
compressions approximately every two minutes;
l Following defibrillation, start chest compressions
immediately, without checking for a pulse (Deakin
et al, 2005).

Ventilations
When performing ventilations an inspiratory time of
one second should be sufficient to achieve chest rise
similar to normal breathing (Soar and Spearpoint,
2005) and minimise interruptions to chest
compressions. The initial two ventilations are no
longer recommended except in a minority of
situations, such as near drowning. Otherwise, CPR
should begin with chest compressions.
Most practitioners are unwilling to undertake
mouth-to-mouth resuscitation for a variety of
reasons, including perceived risk of infection and
distaste of the procedure (Handley, 2005). If there
is a clinical reason to avoid mouth-to-mouth
ventilation, such as a perceived risk of infection, or if
the rescuer is unable or unwilling to perform it,
provide chest compressions only until further help
and equipment arrive. Appropriate resuscitation
equipment should always be immediately available
in the hospital setting.
Defibrillation
In-hospital defibrillation should be performed as
soon as possible within three minutes of arrest
(Soar and Spearpoint, 2005).
The three-shock sequence for a resistant
shockable rhythm is no longer recommended. After
the first shock, compressions and ventilations (30:2)
should be performed for two minutes before
undertaking a pulse/ECG rhythm check, to minimise
the no-bloodflow time. Further shocks are only
delivered after additional two-minute periods of CPR
(Chamberlain, 2005).
The recommended initial energy level when
using a biphasic defibrillator is 150200J, with
second and subsequent shocks at 150360J (if using
a monophasic defibrillator the initial and subsequent
shocks should be 360J) (Deakin et al, 2005).
Defibrillation is no longer recommended if there
is uncertainly over whether the ECG trace is asystole
or fine ventricular fibrillation (VF) because it is
unlikely to result in a perfusing rhythm: continue
with CPR (Soar and Spearpoint, 2005).

The use of an automated external defibrillator

(AED) should be considered by nurses to be part of
their role (Davies, 2005).

Epinephrine (adrenaline)
In ventricular fibrillation/ventricular tachycardia,
epinephrine (adrenaline) is only administered if
the rhythm persists after the second shock. In
asystole and pulseless electrical activity, it should
be administered as soon as IV access is achieved
(Deakin et al, 2005). It is then repeated every
35 minutes.
Treatment algorithms
The adult and paediatric basic and advanced
algorithms have been updated to reflect changes in
the 2005 guidelines. Every effort has been made to
keep the algorithms simple, yet make them
applicable to cardiac arrest victims in most
circumstances (Colquhoun and Nolan, 2005).
Post-resuscitation care
Interventions in the post-resuscitation period can
significantly influence the final outcome (Deakin et
al, 2005). In particular, therapeutic hypothermia
(cooled to 3234C) is now indicated in unconscious
adult patients with a spontaneous circulation
following an out-of-hospital VF arrest (Deakin et al,
2005). In addition, mild hypothermia may benefit
unconscious adult patients with a spontaneous
circulation following an out-of-hospital cardiac arrest
due to a non-VF arrest or following an in-hospital
arrest (Deakin et al, 2005). Hyperthermia should
be treated.
Paediatric resuscitation
There have been a number of changes to the way
paediatric resuscitation is performed, partly as a
result of new scientific evidence and partly to
simplify teaching and retention (Bingham et al,
2005). The main changes are as follows:
l Age definition for a child: from one year to
puberty;
l Start resuscitation with five ventilations priority
is oxygenation;
l The ratio for compressions to ventilations is 15:2
(30:2 for a lone or layperson rescuer);
l Chest compressions in children use one or
two-handed technique according to preference;
l Treatment for foreign body airway obstruction has
been simplified depending on whether the child is
conscious or unconscious;
l Ideally administer medications via the IV or
intraosseous (IO), rather than the tracheal, route;
l Cuffed or uncuffed tracheal tubes can be used in
the hospital setting;
l As in adults, the three-shock sequence for a
resistant shockable rhythm is no longer

NT 17 January 2006 Vol 102 No 3 www.nursingtimes.net

keywords n Resuscitation n Cardiac arrest

Fig 1. The chain of survival (adapted from Nolan et al, 2005)

Early recognition and call for

help to prevent cardiac arrest

Early CPR to buy time

Post-resuscitation care
to restore quality of life

Early defibrillation
to restart the heart

Guidelines

References
International Liaison Committee
on Resuscitation (2005)
International Consensus on
Cardiopulmonary Resuscitation.
www.erc.edu/index.php/ilcor/en
Kause, J. et al (2004) A comparison
of antecedents to cardiac arrests,
deaths and emergency intensive
care admissions in Australia and
New Zealand, and the United
Kingdom: the ACADEMIA study.
Resuscitation; 62: 275282.
Kern, K. et al (1998) Efficacy of
chest compression-only BLS CPR in
the presence of an occluded airway.
Resuscitation; 39: 179188.

recommended; after the first shock, compressions

and ventilations (15:2) should be performed for two
minutes (see above);
l If using a manual defibrillator, the shock energy
for children is 4J/kg for all shocks;
l A standard AED can be used in children over eight
years of age; for younger children, ideally use a
paediatric system such as paediatric pads, as these
automatically select an appropriate energy level.
However, if the only defibrillator available is an AED,
use this;
l The standard dose for adrenaline (epinephrine) in
cardiac arrest is 10mcg/kg higher doses are no
longer routinely recommended (Bingham et al, 2005).

Newborn resuscitation
The main changes for newborn resuscitation are
as follows:
l A food-grade plastic wrapper can be applied to
significantly premature babies to maintain body
temperature;
l The aspiration of meconium from the nose and
mouth of the unborn baby, while the head is still on
the perineum, is no longer advocated;
l If indicated, ventilations can be started with air;
however, additional oxygen should be available if
the baby does not rapidly improve;
l Adrenaline (epinephrine) should be administered
intravenously or via the intraosseous route because
standard doses are unlikely to be effective if
the tracheal tube route is used;
l If there are no signs of life after 10 minutes
of continuous and adequate resuscitation, it
may be justified to discontinue resuscitation
(Richmond, 2005).

Implementing the new guidelines

There are a number of major changes in the new
guidelines and this will result in delays in their
implementation. At a local level, this process of

NT 17 January 2006 Vol 102 No 3 www.nursingtimes.net

change will ideally be overseen by the trusts

resuscitation committee. Nationally, the
Resuscitation Council (UK)s courses are in the
process of being revised and updated, with new
teaching materials being developed, which will be
ready during 2006.
During the transition period, the Resuscitation
Council (UK) has acknowledged that there will
undoubtedly be some variation in resuscitation
practice between individuals and between health
care organisations.
It must be stressed that the publication of the
guidelines does not imply that current clinical
care is either unsafe or ineffective (Colquhoun
and Nolan, 2005). While awaiting the local
implementation of the new guidelines, continue
with current practice, as it would be unhelpful at a
resuscitation attempt if conflicting guidelines were
being followed. For further advice contact a local
resuscitation officer.

Implications for nurses

Following the publication of the new resuscitation
guidelines, nurses must ensure their skills and
knowledge are updated and that they are competent
to carry out resuscitation at a level appropriate
for their clinical role.
All nurses should at least be proficient in basic
life support with the use of airway adjuncts and
basic ventilatory devices as appropriate. They
should also consider the use of an AED to be part
of their role (Davies, 2005).
Nurses should liaise with their resuscitation
officer who can advise on the date for going live
with the new resuscitation guidelines. AEDs will
need to be reprogrammed in line with the new
guidelines, for example to ensure voice prompts
and energy levels are appropriate (RCUK, 2005b).
The full guidelines are available from the www.
resus.org.uk website. n

Nolan, J. (2005) European

Resuscitation Council Guidelines
for Resuscitation 2005 section 1.
Introduction. Resuscitation; 67S1:
S3S6.
Nolan, J. et al (2005) European
Resuscitation Council Guidelines
for Resuscitation 2005 Section 4.
Adult advanced life support.
Resuscitation; 67S1, S39S86.
Resuscitation Council (UK) (2005a)
Resuscitation Guidelines 2005.
London: Resuscitation Council UK.
Resuscitation Council (UK) (2005b)
Statement on the Use of AEDs
(Interim Period until AED has been
Re-programmed). www.resus.org.uk
Richmond, S. (2005) Newborn
Life Support in Resuscitation
Guidelines 2005. London:
Resuscitation Council UK.
Soar, J., Spearpoint, K. (2005)
In-hospital resuscitation. In: RCUK.
Resuscitation Guidelines.
London: RCUK.

This article has been double-blind

peer-reviewed.
For related articles on this subject
and links to relevant websites see
www.nursingtimes.net

27