18 de 0ctubre de 2010 www.elsuapdetodos.com1260 J.P. Nolan et al. / <strong>Resuscitation</strong> 81 (2010) 1219–1276• Personal and environmental risks be<strong>for</strong>e starting <strong>CPR</strong>.• Recognition of cardiac arrest by assessment of responsiveness,opening of the airway and assessment of breathing. 4,13• Recognition of gasping or abnormal breathing as a sign of cardiacarrest in unconscious unresponsive individuals. 69,715• Good quality chest compressions (including adherence to rate,depth, full recoil and minimizing hands-off time) and rescuebreathing.• Feedback/prompts (including from devices) during <strong>CPR</strong> trainingshould be considered to improve skill acquisition and retentionduring basic life support training. 716• All basic life support and AED training should aim toteach standard <strong>CPR</strong> including rescue breathing/ventilations.Chest compression-only <strong>CPR</strong> training has potential advantagesover chest compression and ventilation in certain specificsituations. 694,699,702,707,708,711,717,718 An approach to teaching <strong>CPR</strong>is suggested below.Standard <strong>CPR</strong> versus chest compression-only <strong>CPR</strong> teachingThere is controversy about which <strong>CPR</strong> skills different types ofrescuers should be taught. Compression-only <strong>CPR</strong> is easier andquicker to teach especially when trying to teach a large numberof individuals who would not otherwise access <strong>CPR</strong> training.In many situations however, standard <strong>CPR</strong> (which includes ventilation/rescuerbreathing) is better, <strong>for</strong> example in children, 84asphyxial arrests, and when bystander <strong>CPR</strong> is required <strong>for</strong> morethan a few minutes. 13 A simplified, education-based approach isthere<strong>for</strong>e suggested:• Ideally, full <strong>CPR</strong> skills (compressions and ventilation using a 30:2ratio) should be taught to all citizens.• When training is time-limited or opportunistic (e.g., EMStelephone instructions to a bystander, mass events, publicitycampaigns, YouTube ‘viral’ videos, or the individual does not wishto train), training should focus on chest compression-only <strong>CPR</strong>.• For those trained in compression-only <strong>CPR</strong>, subsequent trainingshould include training in ventilation as well as chestcompressions. Ideally these individuals should be trained incompression-only <strong>CPR</strong> and then offered training in chest compressionswith ventilation at the same training session.• Those laypersons with a duty of care, such as first aid workers,lifeguards, and child minders, should be taught how to do chestcompressions and ventilations.• For children, rescuers should be encouraged to use whicheveradult sequence they have been taught, as outcome is worse ifthey do nothing. Non-specialists who wish to learn paediatricresuscitation because they have responsibility <strong>for</strong> children (e.g.,parents, teachers, school nurses, lifeguards etc), should be taughtthat it is preferable to modify adult basic life support and givefive initial breaths followed by approximately one minute of <strong>CPR</strong>be<strong>for</strong>e they go <strong>for</strong> help, if there is no-one to go <strong>for</strong> them. Chestcompression depth <strong>for</strong> children is at least 1/3 of the A-P diameterof the chest. 8Citizen-<strong>CPR</strong> training should be promoted <strong>for</strong> all. However beinguntrained should not be a barrier to per<strong>for</strong>ming chest compressiononly<strong>CPR</strong>, preferably with dispatcher telephone advice.Basic life support and AED training methodsThere are numerous methods to deliver basic life support andAED training. Traditional, instructor-led training courses remainthe most frequently used method <strong>for</strong> basic life support and AEDtraining. 719 When compared with traditional instructor-led training,well designed self-instruction programmes (e.g., video, DVD,computer driven) with minimal or no instructor coaching canbe effective alternatives to instructor-led courses <strong>for</strong> laypeopleand healthcare providers learning basic life support and AEDskills. 720–734 It is essential that courses include hands-on practiceas part of the programme. The use of <strong>CPR</strong> prompt/feedback devicesmay be considered during <strong>CPR</strong> training <strong>for</strong> laypeople and healthcareprofessionals. 716Duration and frequency of instructor-led basic life support andAED training coursesThe optimal duration of instructor-led basic life support andAED training courses has not been determined and is likely tovary according to the characteristics of the participants (e.g., layor healthcare; previous training; age), the curriculum, the ratio ofinstructors to participants, the amount of hands-on training andthe use of end of course assessments.Most studies show that <strong>CPR</strong> skills such as calling <strong>for</strong> help, chestcompressions and ventilations decay within 3–6 months after initialtraining. 722,725,735–740 AED skills are retained <strong>for</strong> longer thanbasic life support skills alone. 736,741,742Advanced level trainingAdvanced level training curriculumAdvanced level training is usually <strong>for</strong> healthcare providers. Curriculashould be tailored to match individual learning needs, patientcase mix and the individual’s role within the healthcare system’sresponse to cardiac arrest. Team training and rhythm recognitionskills will be essential to minimize hands-off time when using the2010 manual defibrillation strategy that includes charging duringchest compressions. 117,743Core elements <strong>for</strong> advanced life support curricula shouldinclude:• Cardiac arrest prevention. 192,744• Good quality chest compressions including adherence to rate,depth, full recoil and minimising hands-off time, and ventilationusing basic skills (e.g., pocket mask, bag mask).• Defibrillation including charging during compressions <strong>for</strong> manualdefibrillation.• Advanced life support algorithms.• Non-technical skills (e.g., leadership and team training, communication).www.elsuapdetodos.comAdvanced level training methodsA variety of methods (such as reading manuals, pretests and e-learning can be used to prepare candidates be<strong>for</strong>e attending a lifesupport course 745–753Simulation and realistic training techniquesSimulation training is an essential part of resuscitation training.There is large variation in how simulation can be and is used <strong>for</strong>resuscitation training. 754 The lack of consistent definitions (e.g.,high vs. low fidelity simulation) makes comparisons of studies ofdifferent types of simulation training difficult.Advanced life support training intervalsKnowledge and skill retention declines rapidly after initialresuscitation training. Refresher training is invariably requiredto maintain knowledge and skills; however, the optimal frequency<strong>for</strong> refresher training is unclear. Most studies show
that advanced life support skills and knowledge decayed whentested at three to 6 months after training, 737,755–762 two studiessuggested seven to 12 months, 763,764 and one study 18months. 765The ethics of resuscitation and end-of-life decisionsSeveral considerations are required to ensure that the decisionsto attempt or withhold resuscitation attempts are appropriate, andthat patients are treated with dignity. These decisions are complexand may be influenced by individual, international and localcultural, legal, traditional, religious, social and economic factors. 766The 2010 ERC <strong>Guidelines</strong> include the following topics relatingto ethics and end-of-life decisions.• Key principles of ethics.• Sudden cardiac arrest in a global perspective.• Outcome and prognostication.• When to start and when to stop resuscitation attempts.• Advance directives and do-not-attempt-resuscitation orders.• Family presence during resuscitation.• Organ procurement• Research in resuscitation and in<strong>for</strong>med content.• Research and training on the recently dead.Appendix B. Author conflicts of interestAuthorGamal Abbas KhalifaAnette AlfonzoJanusz AndresHans-Richard ArntzJohn BallanceAlessandro BarelliMichael BaubinDominique BiarentJoost BierensBob BinghamLeo BossaertBernd BöttigerHermann BruggerAntonio CaballeroPascal CassanMaaret Castrén18 de 0ctubre de 2010 www.elsuapdetodos.comJ.P. Nolan et al. / <strong>Resuscitation</strong> 81 (2010) 1219–1276 1261Conflict of interestAcknowledgementsMany individuals have supported the authors in the preparationof these guidelines. We would particularly like to thankAnnelies Pické and Christophe Bostyn <strong>for</strong> their administrative supportand <strong>for</strong> co-ordinating much of the work on the algorithms,and Bart Vissers <strong>for</strong> his role as administrative lead and memberof the ERC <strong>Guidelines</strong> Steering Group. The algorithms were createdby Het Geel Punt bvba, Melkouwen 42a, 2590 Berlaar, Belgium(hgp@hetgeelpunt.be).Appendix A. ERC <strong>Guidelines</strong> Writing GroupGamal Abbas, Annette Alfonzo, Hans-Richard Arntz, John Ballance,Alessandro Barelli, Michael A. Baubin, Dominique Biarent,Joost Bierens, Robert Bingham, Leo L. Bossaert, Hermann Brugger,Antonio Caballero, Pascal Cassan, Maaret Castrén, Cristina Granja,Nicolas Danchin, Charles D. Deakin, Joel Dunning, Christoph Eich,Marios Georgiou, Robert Greif, Anthony J. Handley, Rudolph W.Koster, Freddy K. Lippert, Andrew S. Lockey, David Lockey, JesúsLópez-Herce, Ian Maconochie, Koenraad G. Monsieurs, NikolaosI Nikolaou, Jerry P. Nolan, Peter Paal, Gavin D. Perkins, ViolettaRaffay, Thomas Rajka, Sam Richmond, Charlotte Ringsted, AntonioRodríguez-Núñez, Claudio Sandroni, Gary B. Smith, Jasmeet Soar,Petter A. Steen, Kjetil Sunde, Karl Thies, Jonathan Wyllie, DavidZideman.NoneFull time NHS ConsultantNoneEmployer: Charite – Universitätsmedizin –Berlin (paid)Paid lecturer <strong>for</strong> Boehringer Ingelheim, Sanofi Aventis, Daiichi-Sankyo (all lectures on acute coronary care)Merck Sharp & Dohme on lipid disorders (total
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