Basic Life Support
( Cardiopulmonary Resuscitation )

*Learn the recommended method of BLS here.
Introduction
Millions of the public have been instructed in a method of BLS as currently recommended by the American Heart Association (AHA), the method having been little changed over the last 40 or more years. The disappointing results, as regards lives meaningfully saved, are only too apparent to emergency physicians and casualty officers who receive in their departments, victims who had BLS performed by members of the public who had, at one time or other, received training in BLS following the recommendations of the AHA. The efficiency and safety of the method, used by the first to attempt resuscitation of a person believed to be in cardiac arrest, are both crucial in a time period which could short or long before professional help arrives. Not all cardiac arrested victims can expect professional help to arrive within a few minutes. Much depends on the availability of ambulance rescue facilities in the area.

The author first criticized the currently recommended method of performing BLS in 1988. Some of the references following the text will point to articles and letters published in the International Journal ‘Resuscitation’ published by the Elsevier Press in Ireland. The author’s recommendations received only negative comments, the first by Dr. Peter Safar. How BLS is taught today is influenced by the recommendations drawn from conclusions made from the studies of Safar, Escarraga and Elam as published in 1958. Their conclusions were that an attempt to resuscitate should be by mouth-to-mouth respiratory assistance alternating with chest compressions, therefore dictating that the victim lie in the supine position (lying on the back). A critical analysis of their conclusions will be presented.

An interesting comment that should be made is the apparent slowness of change in recommended treatments or medical procedures. Thirty years ago, enthusiastic surgeons increased the drama of apparent sudden death by advocating instant thoracotomy (slicing open the chest) and manual compression of the heart. Some surgeons must have been surprised to feel the heart still beating without their help if they had judged cardiac arrest by not being able to feel the carotid pulse in the neck of a person who had fainted and had a low blood pressure. I believe the first case reported of such drastic therapy occurred on a golf course, which hole was being played was not mentioned. That was one of the few examples when a procedure was not recommended for any length of time. In order not to test the patience of the reader, The author will first present his recommended method of primary BLS for the public:

1. Place the victim who has collapsed, face down on a firm surface if not already in that position.

2. Pull either of the victim’s arms under the forehead so that the bridge of the nose rests on the bent elbow, the nose pointing straight down.

3. Straddle the victim to sit on the buttocks, placing the hands on the back of the chest, one on each side.

4. Rocking forward, press on the chest approximately 40 times a minute, allowing the chest to re expand before the next pressure.

Note- 2. The maneuver allows the chin to fall and open the airway without any obstruction by the tongue, should the patient be in cardiac arrest. If the victim is NOT in cardiac arrest, as may be possible, the procedure will do no harm. Compare the above with the recommendations for performing BLS seen on posters presently placed in public places. The instructions on those posters take a considerable time to read and are easily forgotten.

For those who have taken an AHA course on CPR (BLS), usually at an expense of $20, the retention of what has been taught is dismal when participants of the courses are reevaluated on their retention of the details of the course 3 months later. To only consider how to place the head of a victim, hold the nose, how hard to blow into the mouth, the order and number of times ventilation should be replaced by compressions, shifting positions, while a spouse or relative is most likely in a panic, does not make for any confidence the taught method will be accurately remembered or performed. What has just been mentioned, pictures a victim’s collapse in the home.

Should the collapse occur elsewhere or out of doors, and only strangers are around who might commence BLS, one has to consider the public’s aversion to giving mouth-to-mouth ventilation to a stranger, knowing the present day chances of contracting a disease, one that could be fatal. The AHA recommends carrying a one-way face mask to prevent contamination of the rescuer. Hands up all those who carry one of these masks at all times?

It is not surprising that mouth-to-mouth ventilation showed the best results as regards the largest tidal volume of air produced. On the basis of those findings, ventilation in CPR has been taught encouraging the mouth-to-mouth method, which requires the victim to be supine, lying on their backs.

Although this may have seemed reasonable in 1958, some serious disadvantages can be ascertained by examining the use of that method.

Before listing the advantages of the method suggested by the author, consideration should be given as to what tidal volume is necessary to resuscitate. Consider how deeply a person is breathing while at rest and what tidal volume is necessary to stay alive.

Advantages of the method suggested by the author:

1. Ease of learning the method and knowledge easily retained.

2. Airways automatically opens and the tongue does not obstruct the airway.

3. No air is blown into the victim’s stomach as it is in the current recommended method. This has the disadvantage of risking regurgitation of stomach contents polluting the airway with possible inhalation into the lungs, at the same time elevating the diaphragm reducing the capacity of the chest cage.

4. No risk of mouth-to-mouth contamination of rescuer from the victim or of the victim from the rescuer.

5. Air inhaled by the victim is ambient, as it does not contain the rescuer’s expired air, some of which has less than the desired amount of oxygen and more carbon dioxide..

6. Rescuer does not have to switch positions between compressions and ventilations as they are performed with the same maneuver.

7. No readjustment of head and neck positions necessary before ventilating as required in current AHA CPR.

8. Chest compressions and ventilatory assists are continuous without the breaks needed by the switching of positions as presently recommended by AHA.

9. Should the victim not be in a state of cardiac arrest, and only in a fainting situation, the subject will not be damaged.

10. Only one rescuer is required and the method is practical in a limited space such as is found in the aisles between seats on aircraft.

11. The strain of continuing the resuscitation attempt is minimized compared to that of the currently recommended method.

12. The pressure on the victim’s belly on the floor during compressions simulates a modified Heimlich maneuver.

13. The suggested method can be taught and practiced on live subjects without harm to them and without the necessity for expensive equipment.

14. Frail ribs are less likely to be broken, avoiding internal chest damage. It should be noted that all the advantages listed above are the disadvantages of the method currently promulgated by the AHA.

Further to be noted is that only a part of the right side of the heart is under the sternum (breast bone), the major mass of the heart is towards the left. Compression on the sternum does little to compress the larger ventricles and the heart is only rotated with little compression on its major chambers. What circulation is promoted is from the changing pressures within the chest cavities, but the rate of compressions as recommended by the AHA is too fast to properly allow the thorax to re expand between compressions.

Addendum
In the very early days of Advanced Cardiac Life Support (ACLS), the author was an observer in an emergency department in a country not to be mentioned, when a young woman was rushed in receiving full blown ACLS by a trained ambulance crew. The emergency physicians took over with the help of a cardiologist who had been warned to be present. The treatment could not have been more intense for more than half an hour before the patient was pronounced dead. A lesson was duly learnt when, as the nurses turned the patient over to remove the clothes, a fresh bullet wound came to light in her back.

It is a sad story, but in some way there is a certain dark humor in it. There is also the lesson that every patient who collapses has not had a primary heart attack. There is a long list of other conditions that can cause collapse; very low blood sugar in a diabetic patient taking insulin, sudden internal hemorrhage, spontaneous rupture of the aorta, a blood vessel bursting in the brain, pulmonary embolism, severe allergic reaction to insect bites or drugs, not to mention bullet wounds. The author can at least say that if my method of BLS had been used, and the victim turned into the prone position, the bullet wound would have been discovered and different investigations performed and different therapy applied.

Studies giving support to the author’s recommendations for a change in the teaching of BLS to the public.

References
1. Weisfeldt MI, Chndra N, Tsitlik J; Increased thoracic pressure- not direct heart compressions -causes the rise in intravascular pressures during CPR in dogs and pigs. Crit Care Med 1981.
2. Sean P Mazer, Myron Weisfledt, Diane Bai, Carol Cardinale, Rohit Arora, Cecilia Ma, Robert R Sciaccab, David Chong, LeRoy E Rabbani
3. Resuscitation June 2003 Vol 57 issue 3 Pages 279-285 Reverse CPR, a pilot study of CPR in the prone position.
4. Safar P, Escarraga I, Elam J; comparison of the mouth-to-mouth and mouth-to-airway methods of artificial respiration with the chest-pressure-arm- lifting methods. N Eng J Med 258-671,1958
5. E. McNeil. Re-evaluation of Cardiopulmonary Resuscitation. Resuscitation. Vol 16 No.1 October 1989. pages1-5
6. Stewart JA. Resuscitating an idea; prone CPR. Resuscitation 2002:54.231-6
7. American Heart Association in collaboration with the International Liaison Committee on Resuscitation and emergency cardiovascular care. Part 3. adult basic life support. Resuscitation 2000:46-29-71
8. E. McNeil. Letter to Editor, Resuscitation 56 (2003) 229-233 Re-evaluation of cardiopulmonary resuscitation.
9. E. McNeil. Cardiac Resuscitation: a panacea or an ethical decision? Journal of the Royal Society of Medicine Vol 84 Aug 1990
10. E. McNeil. Presentation. International Academy of Aviation and Space Medicine, London, UK 1995. CPR in the Aviation Environment.
11. E. McNeil. Presentation. International Academy of Aviation and Space Medicine. Budapest, Hungary 1999. Revised CPR in the Aviation Environment..
12. E. McNeil. Text Book. ’Airborne Care of the Ill and Injured’ 1983. Publisher-Springer-Verlag, New York, Inc. pages 169-160. Cardiopulmonary Resuscitation on Board Light Aircraft 13 E. McNeil. Letter. Prone CPR aboard aircraft. J Emerg News 1994.20(6)-446.
13. Lowenthal A, De Alberquerque AM et al Efficiency of external cardiac massage in a patient in prone position. Ann Fr Anesth Reanim 1993:12-587-9
14 Tobias JD, Mencio GA, et al. Intraoperative cardiopulmonary resuscitation In the prone position. J Pediatr Surg 1994-29-1537-8
15 Dequin P-F, Hazouard E, et al Cardiopulmonary resuscitation in the prone Position. Kouwenhoven revisited. Interns Care Med 1996:22:1272-82
16 Kelleher A, Mackenzie A, et al. Cardiac arrest and resuscitation of a 6 month Cardiac arrest and resuscitation in a 6 month old achondroplasic baby undergoing neurosurgery in the prone position Anaesthesia 1992 85-2346-55