General (4)

General Questions and Answers

The Australian Resuscitation Council is a voluntary co-ordinating body which represents all major groups involved in the teaching and practice of resuscitation. The ARC is sponsored by the Royal Australasian College of Surgeons and the Australian and New Zealand College of Anaesthetists.

The Australian Resuscitation Council produces Guidelines to meet its objectives in fostering uniformity and simplicity in resuscitation techniques and terminology. Guidelines are produced after consideration of all available scientific and published material and are only issued after acceptance by all member organisations. This does not imply, however, that methods other then those recommended are ineffective. It is the policy of the Australian Resuscitation Council to respect the autonomy of member organisations.

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The Australian Resuscitation Council meets three times a year at the College of Surgeons in Melbourne.

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You can find the guidelines by clicking here.

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Click here to go to the membership page. There are links here to most of our members web sites.

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Subscription (3)

ARC Subscription Questions and Answers

When the ‘authentication’ box pops up, make sure you enter your username and password EXACTLY as supplied. These details are case-sensitive. If you still can’t get your password to work then please contact the Head Office.

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You can find the guidelines by clicking here.

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To become a subscriber to the Australian Resuscitation Council you need to take out the yearly subscription of $66. The subscription allows you access to the Subscriber Only link on the ARC website which contains an extensive document library. Subscribe via the Renew ARC Subscription link: “Online” payments using credit card or “Offline” by printing out a Tax invoice and forwarding with payment.

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Treatment & Research (4)

Questions and Answers about Treatment and Research

You can find the guidelines by clicking here.

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A recently published study in the New England Journal of Medicine, and an accompanying editorial have thrown down the gauntlet to those organisations that produce guidelines for cardiac arrest management. In this large European study, the investigators evaluated the potential role of vasopressin as the initial vasopressor in the management of out-of-hospital cardiac arrests. Two doses of either vasopressin (40 Units) or adrenaline (1 mg) were administered to patients who required vasopressor support (in accord with European Resuscitation Council guidelines). Across the board, there were no differences in rates of hospital admission or hospital discharge but two post-hoc observations did however raise some interesting points. Firstly, there was a small but significant increase in the hospital discharge rates with vasopressin when the initial cardiac rhythm was asystole. Secondly, the benefits associated with vasopressin seemed to be associated with patients who did not respond to vasopressin alone, but required additional management with adrenaline.

This study was performed in a pre-hospital setting with physician–staffed emergency medical service units. The time intervals to administration of drugs were long (mean of 8 minutes of untreated [no BLS] cardiac arrest, then 10 minutes more until administration of first dose of study drug). There were some disturbing trends towards increased likelihood of adverse neurological outcomes (eg. coma, and severe cerebral disability) in the survivors from the vasopressor group, and this study contradicts the earlier out-of-hospital study of ventricular fibrillation that found dramatically improved short-term survival advantage with a single dose (40 Units) vasopressin.

The ARC is in the process of completing an evidence-based review, but at this stage no change in management or algorithms are required.

Further reading:

  1. Lindner KH, Dirks B, Strohmenger HU, Prengel AW, Lindner IM, Lurie KG. Randomised comparison of epinephrine and vasopressin in patients with out-of-hospital ventricular fibrillation. Lancet 1997;349(9051):535-7.
  2. Stiell IG, Hebert PC, Wells GA, Vandemheen KL, Tang AS, Higginson LA, et al. Vasopressin versus epinephrine for inhospital cardiac arrest: a randomised controlled trial. Lancet 2001;358(9276):105-9.
  3. Wenzel V, Krismer AC, Arntz HR, Sitter H, Stadlbauer KH, Lindner KH. A comparison of vasopressin and epinephrine for out-of-hospital cardiopulmonary resuscitation. N Engl J Med 2004;350(2):105-13.
  4. McIntyre KM. Vasopressin in asystolic cardiac arrest. N Engl J Med 2004;350(2):179-81.

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In a recent email from the USA, it was quoted: “In what may prove to be the biggest shift in emergency care of cardiac arrest in 40 years, cities across the country are leading a move away from the familiar practice of using mouth-to-mouth resuscitation. (Related Story: Many 911 dispatchers eliminating mouth-to-mouth) In its place, the cities are recommending simple chest compressions pushing down repeatedly on the victim’s chest – to mimic a steady heartbeat. The emergency medical directors who are behind the shift say research in Seattle and Richmond, Va, suggests it will save many lives. (Related story: People die in just a few seconds lost). The movement became a full-fledged national trend last week at a meeting of emergency medical services (EMS) medical directors from 21 of the nation’s largest cities. Doctors from a dozen cities, including New York, Los Angeles and Chicago, decided to make the switch. They join at least seven other cities that are already advising 911callers to do chest compressions without mouth-to-mouth “rescue breathing””.

This issue has received media attention in the USA following a recent meeting of EMS medical directors. There has also been a recent article in the Weekend Australian newspaper. It mainly results from a study by Dr Hallstrom and published in the Critical Care Medicine in 2000. In this study, callers to EMS reporting a cardiac arrest and did not know CPR, were asked if they wanted to be instructed on how to do CPR. Those agreeing were randomised to receive instructions over the phone to either do full CPR or just chest compressions. This is often referred to ‘dispatcher assisted CPR’. The results of the study showed that the number of survivors in each group to be similar (14.6% for compression only vs 10.4% for full CPR)

It is important to note that the findings of this study refer only to situations where no trained bystanders were performing CPR. It shows that giving minimal telephone instructions (ie compressions only) seems to be as effective in terms of survival as giving full CPR instructions over the phone. However, this study does not compare the outcomes of untrained rescuers who receive dispatcher assisted CPR with that of CPR being performed by trained rescuers.

As such, inferring that mouth to mouth is not required when doing CPR is not supported by any clinical evidence. Furthermore, it ignores other causes of cardiac arrest such as drowning, and cardiac arrest in children, where ventilation (ie mouth to mouth) is vital.

Readers should be aware that the recommendations of the EMS directors were that “compression only” CPR advice should be given to callers receiving assistance from EMS dispatchers. It did not recommend removing mouth to mouth ventilation from CPR training or practice, as has been generally presented in the media.

Futher Reading:

  1. Hallstrom AP. Dispatcher-assisted “phone” cardiopulmonary resuscitation by chest compression alone or with mouth-to-mouth ventilation. Crit Care Med 2000;28(11 Suppl):N190-N192.

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The age-old debate about which fluids are best for the resuscitation of patients was thrown into chaos by the meta-analysis published in the BMJ in 1998 by the Cochrane group [1]. This review suggested a 6% increase in mortality for those patients treated with albumin (one additional death for every 17 patients treated).

Much discussion ensued, and further meta-analyses were published, but the major factor lacking was a well-conducted trial to actually answer the question “is albumin safe?”

The Australian and New Zealand Intensive Care Society Clinical Trials Group recently published a definitive study, which comes closer to help us answer this question. This study [2], published with an editorial3 in the prestigious New England Journal of Medicine in May this year, was a multicenter, randomised, double-blind trial to compare the effect of fluid resuscitation with albumin or saline on mortality in a heterogeneous population of patients in the ICU. They randomly assigned 6997 patients who had been admitted to the ICU to receive intravascular-fluid resuscitation with either 4 percent albumin or normal saline for the next 28 days.

There were no significant differences between the groups with regard to mortality, numbers of days spent in the ICU, days spent in the hospital, days of mechanical ventilation or days of renal-replacement therapy. Two pre-specified subsets raised some additional interest when albumin administration was associated with better outcomes in one (“severe sepsis”), but was associated with a trend toward worse outcomes in the other (“trauma”). Again, as with many studies, this publication has probably raised more questions than it answered, but it seems that we can at least answer the question “is albumin safe?” Yes!

  1. Human albumin administration in critically ill patients: systematic review of randomised controlled trials. Cochrane Injuries Group Albumin Reviewers. BMJ 1998;317(7153):235-40.
  2. Finfer S, Bellomo R, Boyce N, French J, Myburgh J, Norton R, et al. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med 2004;350(22):2247-56.
  3. Cook D. Is albumin safe? N Engl J Med 2004;350(22):2294-6.

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ARC Advanced Life Support Courses (52)

ARC Advanced Life Support Courses

Yes. The ARC has two Advanced Life Support Courses.

This course will meet the needs of those who need more advanced skills than those taught during Basic Life Support (BLS) but who do not require the more comprehensive 2-day ARC Advanced Life Support Level 2: Advanced Life Support (ALS2/ALS) Course.

ARC Advanced Life Support Level 1: Immediate Life Support Course.

This course is advanced life support for the immediate period of crisis. It is aimed at those participating as team members in critical events. To train healthcare personnel in causes and prevention of cardiopulmonary arrest, the ABCDE approach, initial resuscitation and defibrillation (manual and / or AED) and airway management. It is an advanced life support course that covers the needs of many healthcare professionals. The course is suited to many nursing, medical and paramedical staff. A half-day recertification course is available to recertify within two years of the last certification.

ARC Advanced Life Support Level 2: Advanced Life Support Course.

This course is designed for healthcare professionals who would be expected to apply the skills taught as part of their clinical duties, or to teach them on a regular basis. This includes those expected to team lead in medical emergencies.

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All courses have a component of pre-reading and preparation for candidates. ALS1/ILS Courses: candidates are sent material at least two weeks in advance. ALS2/ALS Courses: candidates are sent material at least four weeks in advance.

As the material must be sent 2 or 4 weeks in advance, most courses will close to applications at or prior to this time. However many courses are booked to capacity well in advance of these dates so it is best to apply as early as possible. Some centres operate a waiting list for candidates in case of candidate withdrawal or increased candidate capacity.

Please note the course assessments will be in the standard format and not be adjusted or altered if you gain a late candidate place or following the pre-course material being sent out to other candidates.

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The Courses are listed on the website in the ALS Courses link. Open the level course you wish to attend and review the course centres and dates to choose one appropriate to you. Some will be listed as restricted by the centre where they only accept internal or restricted applications.

Next to the centre will be a contact or link to apply for the course. Contact the centre directly as application processes vary from centre to centre.

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Course centres set their own course attendance fees. Fees for certification to the ARC for each candidate is set. Centres then set the difference to cover their costs in running the course.

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Yes. The ALS1/ILS and ALS2/ALS are advanced life support courses that include assessment of basic life support measures. Many professional colleges accept this including RACGP, ACRRM, ANZCA, CICM, RCNA, ACEM, and RACP.

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Yes. Candidates attending the course are educated on the causes and prevention of cardiac arrest and participate in practical assessment of patients using a structured approach. This ABCDE approach stresses the early recognition of the deteriorating patient and how to treat patients in the immediate period of crisis.

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Yes. Candidates are exposed to the team environment throughout the course. They work in small teams for the whole course and undertake different roles within those teams. There is no specific session to include the non-technical skills as a separate entity, but the scenarios include instructor led feedback that may raise these. Within the manual for each course is a chapter on Human Factors including task management and ISBAR handover.

Non-technical skills can be defined as the cognitive, social and personal resource skills that complement technical skills and contribute to safe and efficient task performance. More simply, they are the things that affect our personal performance. This is difficult to achieve fully without some competence in the technical ability and in the duration of the course. With that in mind the main focus of the course is on the technical skills with attention paid to the non-technical skills in feedback when required.

An optional session included in the course program in ALS1/ILS gives course centres the prospect to design and/or add this topic into the program. This may be written to support the other course material and specifically to meet the local demands of the candidate group.

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No. Candidates cannot successfully complete the course unless they are present throughout the entire course.

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The provider certificate is valid for 4 years from the date of your course for both ALS1/ILS and ALS2/ALS.

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You may recertify by attending the traditional one-day, or the modular course. The recertification course is not an option since your certificate is past its expiry date.

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You can recertify by attending the whole course again or by attending the recertification course.

For ALS2/ALS your original course certificate must be current (not yet expired) to attend the recertification course. If your certificate is still current you can attend a one day ALS2/ALS Recertification Course run at any centre.

To attend the ALS1/ILS recertification provider course, you must be within two years of your most recent certification. Otherwise you must attend the whole course again. ALS1/ILS recertification provider course requirement of two years is set to match the international co-badging partners of the course.

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Contact the course centre you attended, with details of when you attended the course and request they submit an order for a replacement certificate. They may be able to print the paper copy of the certificate in the interim. The ARC will charge a fee for this replacement credit card type certificate to the candidate.

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The payment of any course fees is a contract between the candidate and course centre. The Australian Resuscitation Council has no dominion over the financial matters of course centres. Complaints regarding financial matters should be made directly to the course centre.

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The path to becoming an ALS Instructor begins by attending the ALS Provider course. We are looking for enthusiastic, experienced clinicians and educators to become instructors. The process for becoming an instructor is highly prescribed. Outstanding candidates on the provider course are identified as having instructor potential by the instructors on that course and invited to become instructors themselves.

The faculty may nominate a candidate for Instructor Potential (IP) selection at the final faculty meeting. The Course Director or Course mentors will inform you at the end of the course if you have been identified as an IP.
On completion of an ALS2/ALS Provider Course you can be nominated as an IP for ALS2/ALS or ALS1/ILS.

ALS1/ILS Provider courses can only nominate for Instructor Potential in ALS1/ILS The nomination is a faculty decision based upon your performance during the course. If you are interested in becoming an Instructor it is advised to make the faculty aware during at the earliest opportunity during the course. This may be at the mentor meeting or during breaks.

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No. All Instructors must have undertaken the provider course as a candidate.

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No. Pathway to Instructor status is prescribed in order to protect the standards of the course and it credentialing from international partners, professional colleges and other organisations. Attendance at a provider course as a candidate is essential. Depending on prior experience some components of the pathway may be exempted (for example Instructor Course for Instructors of some other courses).

All cases are evaluated on an individual basis. If you have further queries please contact the ARC National Course Coordinator via email on, arc.courses@surgeons.org

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If you have been nominated for IP you can then complete the Instructor Potential Opt In form on the website in the ARC Instructors Link.

If you are selected and wish to pursue the training you must attend an instructor course and successfully complete teaching practices as an Instructor Candidate (IC) before becoming a full instructor.

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In some cases it is not necessary to complete a further Instructor Course and the Opt In form lists those where you may be exempt from the need to attend the ARC Instructor Course. You should contact the National ARC Course Coordinator via email at arc.courses@surgeons.org if you require further clarification.

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The options here are:

Firstly speak to the Course Director and or your mentors by requesting some feedback on the decision. They may be able to give some insight into the decision and state why the faculty made it.

Attend the ALS Hybrid Instructor Course and complete the ALS1/ILS Instructor development and attend another ALS2/ALS Course with the purpose of nomination for IP in ALS2/ALS. By attending the Hybrid Instructor Course you would not then need to attend another course if successful in ALS2/ALS IP nomination.

Appeal the decision to the ARC by contacting the ARC National Course Coordinator via email on, arc.courses@surgeons.org or the ARC Executive Officer on arc@surgeons.org . They will contact the Course Director and/or Faculty members to review your case. Appeals are assessed by the ARC National Course Coordinator in collaboration with members of the ARC ALS Sub-Committee and kept in strict confidence. All decisions made by the ARC/ALS Sub-Committee are final.

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Firstly speak to the Course Director and or your mentors by requesting some feedback on the decision. They may be able to give some insight into the decision and state why the faculty made it. The Course Director and Faculty may opt to review the situation in a meeting prior to the faculty closure of the course, (following candidates leaving), or following the course.

Appeal (within one year of the course) the decision to the ARC by contacting the ARC National Course Coordinator via email on, arc.courses@surgeons.org or the ARC Executive Officer on arc@surgeons.org. You will need to include full details of where and when you undertook the provider course and your reasons for appeal. You may be asked to provide additional information. All appeals material is kept with strict confidentiality within the ARC.

They will contact the Course Director and/or Faculty members to review your case. Appeals are assessed by the ARC National Course Coordinator in collaboration with members of the ARC ALS Sub-Committee and kept in strict confidence. All decisions made by the ARC/ALS Sub-Committee are final.

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You will need to complete two courses as an Instructor Candidate. Once these are completed successfully you will be recertified. You do not need to commence the whole process again.

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No. The ARC is not a validating organisation and no longer credentials or certifies any other courses. The only courses it validates are courses developed by the ARC (and co-badged with the RC(UK)) because it sets the standards for the program, the teaching scenarios, the instructors, the assessment process and course centres.

Since we have no such control over the standards of other courses we cannot offer any similar guarantee concerning successful participants and do not accept these certificates as equivalent to the ARC courses.
The level of qualification, training and experience needed for any individual clinical role is the responsibility of the employer, not the ARC.

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Yes. ALS certificates provided by the RC(UK) or the ERC are recognised by ARC because these organisations use the same program, teaching material, and assessment process.

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Yes. ALS certificates provided by the NZRC are recognised by ARC because the ARC and NZRC collaboratively develop the ALS guidelines and standards of courses.

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No. The ACLS course curriculum and instructor training is different from that of the ARC and RC(UK). Likewise, the AHA does not recognise the ARC ALS course and instructor training as equivalent to the AHA ACLS course.

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No. The ACCCN course curriculum, instructor selection and training is different from that of the ARC and RC(UK).

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Yes. ALS Instructors from the RC(UK) or the ERC are recognised by ARC because these organisations use the regulations and development pathways. You will need to complete the Current/RC(UK) Instructor Registration Form on the ARC website.

As an RC(UK) Instructor you will need to complete the first course as a ‘Recertifying Instructor’ to ensure you are supported and assessed prior to entry to the ARC Register. Your current recertif

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Yes. As the guidelines are the same and the ALS Courses and Instructor Training is credentialed. You will need to first complete the Current/RC(UK) Instructor Registration Form.

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No. Only ARC approved course centres can run the ARC courses. You can apply to be approved as a course centre.

Please note the ARC reserves the right to refuse course centre applications and review without notice any of those approved. For further information regarding the application process please email the ARC Executive Officer arc@surgeons.org or ARC National Course Coordinator arc.courses@surgeons.org

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There are strict criteria for becoming an ARC approved ALS course centre. Prospective centres should first read the ALS course regulations.

An ALS course centre application form must be submitted to the ARC for approval. A course centre is regarded as the administrative centre from which the course is organised rather than the geographical location of where it is delivered or the person organising it. An ARC Representative must assess the first course and they may attend at any time to revalidate the centre without prior notice. Please contact the ARC for further enquiries via email on arc.courses@surgeons.org .

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No, you do not need to register your all your dates with us in. Please note you may need to submit an approval form prior to the course to inform the ARC of the faculty and candidate numbers.
We do publish on the ARC website the dates of the course centres who inform us of their planned courses, unless you have specifically asked for details not to be published. You can inform the ARC in advance of any additional dates or changes you need making to those published.

It is advised you make the ARC aware of all dates to allow the course instructor candidates or other potential candidates can plan their development and attendance. Course centres with published dates appear to gain the faculty for running of the courses a little more easily.

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Yes. All centres must purchase the advanced life support manual from the Australian Resuscitation Council (that includes candidate certification for the course), and send them to candidates no later than two/or four weeks (depending on course) prior to the course. Following the course the candidate retains the manual for further reading and reinforcement.

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No. The manuals are subject to copyright and should not be copied in any way. There are currently no plans to release the manuals in an electronic format.

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The manuals were fully revised following the introduction of Guidelines 2010. The third edition published in 2011 is the current version. We will give as much notice as possible of any changes however minor in re-prints and updates.

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Yes. All centres must purchase the relevent manual from the Australian Resuscitation Council and are not permitted to produce their own manuals.

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The manual is available to course centres at a standard rate, no matter how many are ordered.

Approved course centres running multiple courses can order in advance to assist planning. The ARC may ask in these cases for outstanding invoices to be settled prior to any further manuals being sent for subsequent courses.

Each manual purchased by the course centre at course rates, includes candidate certification. One manual equates to one candidate certification. Only approved centres can offer this when delivering the course in accordance with the regulations.

Manuals purchased privately from the website will not include any certification from the ARC.

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No. We do not give refunds on out-of-date manuals and cannot replace them with the new version.

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Yes. However the whole program must be completed within eight days.

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The Resuscitation Council recommends that adequate records are kept for a minimum period of the duration of course certification, so that any issues can be dealt with locally if raised. Records should be maintained in line with local policies. Copies may be kept in either paper or electronic formats and may be recalled by the ARC for review at any time during the period of course certification.

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No. There are no plans to change the teaching requirements for ALS2/ALS Instructors.

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No. You must follow the regulations and the standard program. Course approval can be gained by submission of a Course Approval Form informing the ARC of the faculty and candidate numbers at least four or six weeks prior to the course (depending on the course type).

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Yes. ALS1/ILS may be submitted in one form but ALS2/ALS must be submitted each time.

ALS1/ILS: If you have completed the notified the ARC of all the courses in advance ‘Provider Course Publishing Form’ listing all the faculty using the you will be using you do not need to submit individual course approval forms. If you add faculty not listed or have the addition of an Instructor Candidate you must submit an approval form for the individual course. This is to ensure the IC is supported and the course will run to regulation.

ALS2/ALS: Courses must have individual approval forms listing candidate numbers, faculty and Course Director/Medical Lead submitted for each course at least six weeks in advance.

Any additions/changes to faculty following submission or approval must result in an updated approval form being sent to the ARC Executive Officer arc@surgeons.org.

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Yes. The standard program is designed for a maximum of 30 candidates, (6 per group). If you have fewer candidates on the course you may adjust the practice time accordingly. All the scheduled CASTeache scenarios must be used for each course delivered in order.

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Yes. Candidates attending the course may claim points from many professional colleges. Faculty teaching on the course may also claim points. If you have any further queries regarding MOPS/CPE/CME please contact your Professional College.

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For ALS1/ILS – Yes they are but it is advised that anyone undertaking this course has had significant clinical exposure prior to course attendance. Final year medical students are one group that have benefited from this course. Undergraduate nursing students have repeatedly struggled with the content and practical component included and are recommended to consider this course only following graduation and a period of clinical exposure. ALS2/ALS is unsuitable.

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You need to complete the course results sheet form available on the ARC website for each course that you run. Our system will generate certificates for successful candidates, and these will be posted to your centre. Please take care with spelling as the certificates generated will reflect spelling on the results sheet. Any error made on the results sheet resulting in need for replacement cards will be at the cost
of the course centre.

Results sheets includes the IC results and upon successful completion of their development an Instructor Card will be issued.

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No. Certificates are always sent to the ‘nominated named person’ at the address registered for the course centre.

If a course centre runs courses at multiple sites (e.g. different hospitals or venues) they can register one site and should arrange to forward the certificates to the different sites themselves as required.

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You should have received your login information and password when the when you first registered as a new course centre. If you are unsure about your login information or cannot find the link on the website, please email arc@surgeons.org for advice.

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Exceptionally able ALS1/ILS candidates may be nominated for ALS1/ILS instructor training by the faculty. ALS2/ALS providers may also have been identified as potential ALS1/ILS Instructors on their provider course. For further information regarding the selection criteria for ALS1/ILS Instructor course candidates and the nomination procedure please see the nomination form in the course material or
email the ARC National Course Coordinator on arc.courses@surgeons.org or Executive Officer on arc@surgeons.org.

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Yes. Any ARC registered ARC Course Centre can apply to run the Instructor course. Please email arc@surgeons.org for further details. You need to give at least four months notice of dates for the course to be run at your centre.

Options for Instructor Courses:

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In the first instance please check our FAQs on Adult Advanced Life Support. If these do not address your clinical enquiry please email the National ARC Course Coordinator arc.courses@surgeons.org providing clear and full details of the enquiry. Enquiries may be forwarded to the most appropriate sub-committee and are answered as soon as is practical.

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We are not able to share confidential information including email addresses and phone numbers without express permission of the individual. In the updating of contact information Instructors are now asked if they permit the sharing of their email address with ARC Course Centres. Those that will permit this will be shared with all course centres.

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Guidelines (28)

ARC Guideline Questions and Answers

The assessment of a pulse is also controversial. This issue has previously been discussed in detail. It is reasonable for practitioners taught to feel a pulse to do so as part of the assessment for signs of life, but to limit the total time taken to 10 seconds.

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CPR should be performed by a single rescuer until other rescuers are available, then it may be performed by two rescuers (one performing chest compressions and one performing rescue breaths). There is less interruption to chest compressions if the work is shared between the two rescuers, rather than one person doing it all until tired. Frequent rotation of rescuers (especially the rescuer performing chest compressions) should be undertaken to reduce fatigue.

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Guideline 4 outlines the recommended procedure for choking. This is a controversial area mainly as there is a lack of any scientific evidence for making strong clinical guideline recommendations. The Consensus of Resuscitation Science identified that the combination of back blows, chest thrusts and abdominal thrusts could be used to relieve complete foreign body airway obstruction. Where the patient is unconscious then CPR should be used.

It is the use of the chest thrust which appears to be causing some confusion. Chest thrusts are applied:

  • At the same point on the chest that is used when providing chest compressions during CPR.
  • They are delivered sharper and slower than chest compressions during CPR.

In order to do chest thrusts you need to have the back of the patient supported. This can be achieved by either:

  • Placing your other hand on the patients back.
  • If the patient is sitting use your other hand to support the back of the chair.
  • Have someone stand behind to provide support.
  • Stand against a firm surface like a wall.
  • Lie the patient down.

It is very hard to state categorically on how to achieve back support when using chest thrusts but the overall principle remains the same. Support the back any way you can.

Remember if chest thrusts cannot be applied continue with back blows. If the patient becomes unconscious commence CPR. The ARC does not recommend the use of abdominal thrusts as there is considerable evidence of harm caused by this procedure.

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The recommendation to immediately start CPR after a shock is based on the fact that the chance of developing a rhythm associated with an output in the first minute or so after defibrillation is extremely small. Starting CPR immediately after defibrillation, irrespective of the electrical success or otherwise, or the attempt at defibrillation, restores blood flow to the brain and heart and creates an environment more conducive to return of spontaneous circulation. A period of at least 1-2 minutes of good CPR appears to be able to increase the likelihood of success of the next attempt at defibrillation. Obviously there is no need for CPR to continue if signs of life return.

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First-aiders and professionals endeavouring to render assistance to an incompetent person (eg: child, comatose adult) in need of assistance are sometimes faced with requests by family or others to refrain on the grounds that the person would not have wanted assistance or that the treatment proposed is burdensome.

When the situation applies to an incompetent adult (unable to communicate rationally) who has previously stated in writing their intention, the situation is quite clear and the person’s desires must be followed. Of importance, is that spouses and relatives of incompetent adults do not normally have authority to decline treatment of their loved one unless this has been given force by an appropriate legal directive.

If competent adult states that treatment is not wanted, this request should be followed since to do otherwise is ethically and legally wrong.

However, when the situation pertains to a child (an incompetent legal person), the child’s parents or legal guardian have the right to refuse such treatment provided that this is in the ‘best interests’ of the child. However, medical practitioners, and presumably other professional healthcare personnel, also have a duty of care to always act in the ‘best interests’ of the child.

When conflict arises, the question arises: what is meant by ‘best interests’?

Although used freely in medical and legal contexts, the term ‘best interests’ is a nebulous term. With respect to children, legally, Courts are directed to act in the ‘best interests’ of a child in section 68F of the Family Law Act 1975 (Clth). In determining what these might be, consideration must be given to current wishes of the child, relationships with parents and others, any changeable circumstances, the child’s maturity, protection from physical and psychological harm and any other matters that the Court  considers relevant.

From a practical viewpoint, ‘best interests’ may be defined from an examination of common law cases involving incompetent adults and children 1.

Essentially, ‘best interests’ may be defined as:

  1. Avoidance of futile treatment. This is somewhat facile. It leads to the question of: What is futility? What may seem futile to one person is not to another, but from a legal common law perspective, it may be stated as actions that only serve to prolong death rather than save life.
  2. A consideration of the burden versus benefit of treatment. This requires a consideration of the results of withholding treatment versus its application.
  3. Consideration of the quality of life if treatment is given and survival ensues.

When faced with a situation in which it is unclear whether treatment should be given or withheld in the incompetent adult’s ‘best interests’, it is justifiable to give treatment, otherwise a possible benefit may be foregone. If it so happens that treatment is later considered not be beneficial, it can be withdrawn since both ethically and legally, withholding and withdrawing treatment are identical.

  1. Tibballs J. The legal basis for ethical withholding and withdrawing

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The term “cycle” has been deleted from the advanced life support guidelines (11.2 and 12.3) because it conflicted with its proper meaning in Guideline 8 where it signified, and still does, one bracket of chest compression and ventilation, that is, 30 compressions followed by 2 ventilations. Now, treatment described in algorithms of guidelines 11.2 and 12.3 is referred to not as a “cycle” of treatment but rather as a “loop” of treatment where it signifies a single sequence of events including assessment of the cardiac rhythm, determination whether the rhythm is “shockable” or not, 2 minutes of CPR, assessment of return of spontaneous circulation and reassessment of the cardiac rhythm.

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The default defibrillation technique is now to use a single shock technique rather than a salvo of up to three shocks. The main rationale for this approach is to minimise the interruptions to CPR, which have been shown to be associated with a rapidly decreasing diastolic blood pressure (and coronary perfusion pressure) and a decreased likelihood of successful defibrillation. The shock success for currently used defibrillators is actually very high for the initial shock, and the interruptions to CPR for the second and third shocks in succession are thought in most circumstances to be more detrimental than the incremental success from these subsequent shocks.

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In unresponsive adults and children, it is reasonable to open the airway using the head tilt – chin lift manoeuvre. While the value of maintaining an open / patent airway is recognised, there is insufficient evidence to recommend one specific airway opening technique (ARC Guideline 4).

With reference to ARC guideline 4, airway management in children should be managed the same as adults however we know that the upper airway in infants is easily obstructed because of its small diameter, and as the windpipe is soft, it can become compressed and narrowed if excessive backward head tilt is applied.

Therefore, in infants, the head should be kept in a neutral position and maximum head tilt should not be used. If simple airway manoeuvres (chin lift) do not open the airway, then a slight backwards head tilt may be needed to open the airway.

[Class A; LOE Expert Consensus Opinion].

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A frequently asked question is: What compression to ventilation ratio should be used for newborn infants?

The answer depends on the number of rescuers available and their level of training.

For all lay rescuers, a compression to ventilation ratio of 30:2 should be used, as for any resuscitation.

When more than one healthcare professional is available, a compression to ventilation ratio of 3:1 should be used for newborn infants.

Newborns are defined in the ARC guidelines as infants at birth or in the first hours of life. (Ref Guidelines 12.1 & 13.1)

Given the shortage of evidence for compression to ventilation ratios at any age, it is more important that resuscitation teams perform continuous effective CPR according to their usual training, than spending time negotiating what ratio should be used.

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Why should the rescuer pick off tentacles from the victim following a jellyfish envenomation?

It is recommended in ARC guideline 8.9.6 to pick off adherent tentacles from the victim. Although most of the tentacle stinging cells are likely to have already fired, by removing the tentacles, any unfired nematocysts are also removed. This may lessen the venom load to the patient and this reduction may make a difference to the victim’s outcome.

Is it harmful to the rescuer to touch the tentacles while removing them from the victim?

Although most of the nematocysts (stinging cells) will have fired, the small number of remaining unfired cells could cause a mild prickling sensation to be felt by the rescuer. This will not be harmful to the rescuer. Wearing gloves is known to afford protection when picking of the adherent tentacles from the victim.

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New devices that evaluate quality of CPR and the defibrillation waveform offer promise in the management of cardiac arrests, but at this stage they need further study before any recommendations can be made.

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Victims who are just feeling cold, or only suffering mild hypothermia (core temperature greater than 34 degrees), shivering and fully conscious can generally be rapidly re-warmed without risk. A bath of hot water (40 degrees Celsius) under supervision is the best way to do this.

Hot showers are less effective, but often a more practical or available option. Showers have the added risk of rewarming collapse because of low blood pressure. Victims must be supervised and warned to alert the supervisor if they feel even slightly dizzy. If so, they should be removed from the shower to continue rewarming more slowly, e.g. wrapped in warm blankets, sipping warm drinks.

The advantage of active re-warming in a hot bath or shower is that it re-warms the victims quickly, restores the feeling of well-being and reduces the time spent shivering which is both unpleasant and a physiological stress.

Victims of more severe hypothermia or with altered conscious state should not be placed in baths or showers.

Reference: Essentials of Sea Survival (2002) Golden F, Tipton M. pp 272-273

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You can find the guidelines by clicking here.

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Guideline 6 recommends that two fingers should be used to give chest compressions to an infant. (less than 1 year of age) In children where the size of the child and that of the rescuer can vary greatly it is impossible to make a clear recommendation. Guideline 6 recommends two hands for simplicity of BLS training in that one hand may not always be sufficient whereas two hands will always be.

The important focus here is to ensure that the depth of chest compressions is adequate (ie about 1/3 of the chest depth). For some people that will require two hands, for others one hand will be sufficient. Furthermore, when using two hands the full weight of the rescuer may not need to be applied to achieve adequate depth of compressions.

Training should focus on achieving adequate compression depth rather than when to use one or two hands for chest compressions in children. Providing adequate depth of chest compression is achieved the use of one hand is acceptable.

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To determine the need for only rescue breathing you would need to be able to check for a pulse. There is reasonable evidence that rescuers are no more likely to be able to correctly determine if a pulse is present than simply tossing a coin. Accordingly Resuscitation councils all around the world removed the pulse check in 2000. Epidemiological data would suggest that the vast majority of victims requiring resuscitation will be in cardiac arrest – thus requiring full CPR. Furthermore only about half of the victims requiring CPR get any resuscitation before an ambulance arrives. Thus it was considered of greater benefit overall that anyone who is not responsive and not breathing normally should be given CPR rather than not receiving any compressions because the rescuer thought the victim had a pulse. This is very much the case as there is no reliable way for the rescuer to detect a pulse. COMPRESSIONS ARE VITAL.

Will I do harm if I give chest compressions to someone with a beating heart?
There is very little data in this area however you are highly unlikely to do harm. One study has shown that patients who were defibrillated and had immediate CPR for 2 minutes after the shock, regardless of whether a pulse was present or not, were no more likely to have complications. In addition, it is recommended in paediatric resuscitation and common practice in critical care settings for CPR to be given to patients who have a slow heart rate. NO adverse effects have been reported. Based on the available evidence, it appears that the fear of doing harm by giving chest compressions to some who has no signs of life, but has a beating heart, is unfounded.

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There is very little data in this area however you are highly unlikely to do harm. One study has shown that patients who were defibrillated and had immediate CPR for 2 minutes after the shock, regardless of whether a pulse was present or not, were no more likely to have complications. In addition, it is recommended in paediatric resuscitation and common practice in critical care settings for CPR to be given to patients who have a slow heart rate. NO adverse effects have been reported. Based on the available evidence, it appears that the fear of doing harm by giving chest compressions to some who has no signs of life, but has a beating heart, is unfounded.

The guidelines now recommend that full CPR be given to all those requiring resuscitation. What about victims who may not be breathing but have a pulse?

To determine the need for only rescue breathing you would need to be able to check for a pulse. There is reasonable evidence that rescuers are no more likely to be able to correctly determine if a pulse is present than simply tossing a coin. Accordingly Resuscitation councils all around the world removed the pulse check in 2000. Epidemiological data would suggest that the vast majority of victims requiring resuscitation will be in cardiac arrest – thus requiring full CPR. Furthermore only about half of the victims requiring CPR get any resuscitation before an ambulance arrives. Thus it was considered of greater benefit overall that anyone who is not responsive and not breathing normally should be given CPR rather than not receiving any compressions because the rescuer thought the victim had a pulse. This is very much the case as there is no reliable way for the rescuer to detect a pulse. COMPRESSIONS ARE VITAL.

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The optimal sequence of events that should follow for a persistent shockable rhythm is not known. The sequence cannot be prescribed exactly but the general principles that should be followed are listed here.

  • At all times, interruptions to compressions should be minimised.
  • After an unsuccessful attempt at defibrillation a 2-minute period of CPR is recommended before the rhythm is reassessed.
  • If when the rhythm is reassessed a shockable rhythm persists, repeat defibrillation (second shock).
  • After the second attempt at defibrillation on recommencing chest compressions administer 1 mg adrenaline, continue CPR for 2 minutes and then reassess and repeat defibrillation if indicated (third shock).
  • Adrenaline should subsequently be administered at a rate of 1 mg approximately every three minutes until Return of Spontaneous Circulation. For simplicity, adrenaline could be administered in alternate loops. A period of at least 1-2 minutes of good CPR is recommended after each dose of adrenaline to help circulate the drug.
  • If the subsequent attempt at defibrillation is also unsuccessful, a 2-minute period of CPR is again recommended before the rhythm is reassessed.
  • If VF is still present after the administration of adrenaline and one further shock, consider administration of an anti-arrhythmic before defibrillation (fourth shock).
  • At any stage if a rhythm is present that should be associated with a pulse, then formal checking for signs of life (including a pulse check) should be performed. If there are no signs of life (including a pulse) then the non-shockable sequence should be followed.

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The assessment of a pulse is also controversial. This issue has previously been discussed in detail. It is reasonable for practitioners taught to feel a pulse to do so as part of the assessment for signs of life, but to limit the total time taken to 10 seconds.

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The question sometimes arises: why is the recommended compression-ventilation ratio for infants and children different from adults?

A compression-ventilation ratio (external cardiac compression [ECM] + rescue breathing) of 30:2 for basic (one-rescuer) CPR was chosen in the Consensus on Science and Treatment Recommendations for all infants (except newborns, i.e. at birth) children and adults, but a ratio of 15:2 chosen for CPR performed by two healthcare rescuers for infants (except the newly-born) and children whenever a pause is required between compressions to deliver breaths 1,2. These recommendations replace the previous recommendations of 5:1 for two-person rescue of adults, children and infants.

Unfortunately, no studies to determine the optimum compression-ventilation ratio during CPR have been performed in humans, so the recommendations are by extrapolation from studies done in animals, mannequins and computer simulations in which higher compression-ventilation ratios are favoured over lower ratios.

The rationale to recommend a new ratio higher than 5:1 is the following:

  1. A ratio of 5:1 may provide unnecessary ventilation. Cardiac output during good CPR is only 1/4 – 1/2 of normal cardiac output so normal minute ventilation is unnecessary for adequate ventilation- perfusion matching in the lungs, and …
  2. A ratio of 5:1 may obstruct venous return thereby limiting cardiac output
  3. A ratio of 5:1 may excessively lower blood carbon dioxide levels thereby causing cerebral vasoconstriction, and …
  4. A ratio of 5:1 frequently interrupts cardiac compressions, causing blood pressure to fall nearly to zero at each interruption, thereby failing to perfuse the cerebral and coronary vascular beds.

Several studies of the performance of adult CPR 3,4 showed that rescuers spent far too much time NOT giving external cardiac compression (‘hands-off time’) largely because of giving excessive ventilation instead. No equivalent studies have been examined paediatric CPR.

The ratio of 30:2 for adult CPR was chosen to encourage uninterrupted cardiac compression sequences and to decrease unnecessary ventilation.

However, children differ from adults in the following important ways:

  1. The different choice of 15:2 ratio for CPR of infants and children is based largely on the requirement of infants and children for higher ventilation rates than adults, and to a lesser extent on the different aetiology of cardiac arrest in children. Of course, infants and children have a wide range of ventilation during illness, ranging from a normal rate, for example, of up to 60/min at 3 months of age, 40/minute at 1 year and up to 30 minute at 12 years of age. There is also a variability of heart rate among infants and children compared with adults but it is less variable than the respiratory rate. Thus while it is reasonable to choose a fixed cardiac compression rate to suit all infants, children and adults, it is less reasonable to choose a single respiratory rate for infants, children and adults. On the other hand, it is not practical to recommend specific rates of compression and ventilation for each child according to each age.
  2. A much larger proportion of cardiac arrests due to the sudden onset of ventricular fibrillation occur in adults compared with children. In these victims, the lungs can be expected to contain a store of oxygen and thus ventilation is a lesser priority. In children, the incidence of ventricular fibrillation in children who arrest in hospital is approximately 10% 5,6,7 whereas the majority are due to other rhythms (asystole, hypotensive bradycardia and electromechanical dissociation) which are usually the result of hypoxaemia or hypotension or both.

Consequently, the consensus of opinion among the paediatricians who participated in the 2010 evaluation of science on resuscitation remained that ventilation should be emphasised as a prominent part of CPR for infants and children, and that a ratio of 30:2 would result in insufficient ventilation.

If 30:2 then provides insufficient ventilation for infants and children – what is the right ratio? The ratio of 15:2 was chosen because it had already been taught as a ratio for children (for single rescuer CPR), had been used successfully and thus would be less difficult to teach than a completely new ratio. Moreover, since healthcare rescuers are more likely to effect a smooth changeover from compressions to ventilation (and back to compressions) than the lay person rescuer, a 15:2 ratio may be a less severe interruption to compressions. It is realised however, that the ideal ratio remains unknown and the current recommendations need testing.

Companion questions are:

  1. How much ventilation is recommended after intubation and:
  2. How much ventilation is recommended when the circulation returns and ECM is not needed?
  3. If ventilation is provided with the use of an advanced airway (eg endotracheal tube, Laryngeal Mask Airway) – that is by healthcare rescuers – where no pause is required for ventilation, the ratio of 15:2, will provide excess ventilation because if compressions are given uninterrupted at 100/minute, a ratio of 15:2 would provide about 13-14 breaths per minute. That may be more than needed for ventilation-perfusion matching in the lungs, so in this circumstance, about 10 breaths per minute is the recommendation.
  4. If some circulation returns during resuscitation, yet spontaneous ventilation remains inadequate, an imposed ventilation rate of 12-20/minute is recommended. If normal circulation returns, a normal ventilation rate for age should be given
  1. Consensus on science and treatment recommendations. Resuscitation 2010; 81: 213-259. 
  2. Australian Resuscitation Council. Guidelines 7; 12.2. 
  3. Wik L, Kramer-Johansen J, Myklebust H et al. Quality of cardiopulmonary resuscitation during out-of-hospital cardiac arrest. JAMA 2005: 293: 299-304. 
  4. Abella B, Alvarado JP, Myklebust H et al. Quality of cardiopulmonary resuscitation during in- hospital cardiac arrest. JAMA 2005; 293: 305-370 
  5. Samson RA, Nadkarni VM, Meaney PA et al. Outcomes of in-hospital ventricular fibrillation in children. NEJM 2006; 354: 2328-39. 
  6. Young KD, Seidel JS. Pediatric cardiopulmonary resuscitation: a collective review. Anna Emerg med 1999; 33: 195-205. 
  7. Tibballs J, Kinney S. A prospective study of outcome of in-patient paediatric cardiopulmonary arrest. Resuscitation 2006; 71: 310-318.

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Does the ARC provide any guidance on the resuscitation, pre-hospital and emergency care of patients with acute coronary syndromes?

The management of patients with Acute Coronary Syndromes in the pre hospital and emergency care setting has been an area of increased research activity over the last 10 years. It is an area that has often been overlooked in guidelines focused on the management of acute coronary syndrome that have tended to focus on immediate and definitive therapeutic interventions once a clear diagnosis has been established.

The current COSTR process devoted a dedicated Task Force formed from the outset to address 25 topics related to the acute initial management of acute coronary syndromes drawing on expert reviewers from Africa, Asia, Australia, Europe, North America, and South America. The 2010 COSTR has produced an expanded review the available evidence in the area of out of hospital and emergency care of ACS. A complete systematic review of all literature is contained in this document.

For the first time the Australian Resuscitation Council has develop guidelines in this area based on the 2010 COSTR on ACS. Comprehensive guidelines for the diagnosis and treatment of ACS with and without ST elevation have been published by the Cardiac Society of Australia and New Zealand (CSANZ) and the National Heart Foundation (NHF). This section on ACS has been developed to compliment the CSANZ and NHF guidelines.

There are a number of new evaluations that should be highlighted since initial 2005 COSTR that have been outlined in the 2010 document. These include:

Presentation with ACS

  • In isolation the clinical history, clinical examinations, biomarkers, ECG criteria and risk scores are unreliable for the identification of patients who may be safely discharged early in the emergency setting.
  • Chest Pain Observations Units (CPUs) have an important role in the safe and effective evaluation of patients presenting with possible ACS. The use of a protocol that includes serial evaluation o f physical findings, symptoms, ECG, biomarker testing coupled with further provocative testing or imaging procedures are recommended to identify patients who required admission for further testing and treatment.
  • The use of pre- hospital ECG for the diagnosis of ST elevation myocardial infarction is recommended and can be interpreted by a variety of methods including by trained non medical staff in the field, remote transmission or with computer assistance.

Initial Medical Therapy

  • Supplemental oxygen should be initiated for breathlessness, hypoxaemia or signs of heart failure or shock however hyperoxaemia may be harmful in uncomplicated myocardial infarction.
  • Response of chest pain to nitrate therapy is not reliable for diagnostic purposes.
  • Non-steroidal anti-inflammatory drugs other than aspirin should not be administered as they may be harmful in patients with suspected ACS.
  • Aspirin may be given by dispatchers or bystanders provided true allergy or a bleeding disorder can be excluded.
  • Newer anti-platelet agents have an important role in the early management of ACS.

Reperfusion Strategy

  • Clinical reperfusion networks that include emergency medical services and hospitals with an agreed approach to ST Elevation Myocardial Infarction (STEMI) management can be beneficial in achieving best outcomes for patients with ACS.
  • Primary Percutaneous Coronary Intervention (PPCI) is the preferred reperfusion strategy for STEMI when it is performed in a timely manner by an experienced team.
  • Fibrinolysis continues to be an important treatment modality for many patients when PPCI is not available.
  • Acceptable first medical contact to PPCI delays varies depending on the infarct territory, age of the patient, and duration of symptoms.
  • Rescue Percutaneous Coronary Intervention (PCI) should be performed if fibrinolysis fails.
  • Patients may be directed to PPCI capable facilities in the pre hospital setting bypassing closer Emergency Departments if PPCI can be delivered in a timely manner.
  • Patients with successful fibrinolysis but not in a PCI-capable facility should be transferred for angiography and possible PCI at ideally 6–24 h after fibrinolysis. However immediate routine PCI after fibrinolysis or combination fibrinolysis (‘facilitated’) is not recommended.
  • Immediate angiography and PCI is a reasonable approach to patient with return of spontaneous circulation (ROSC) and may be a part of a standardised protocol for the post arrest care of patients.

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Three Stacked Shocks were removed from the standard ALS algorithm as part of the 2010 CoSTR changes. It is now included under the special circumstances in resuscitation guideline.

Where a patient with a perfusing rhythm develops a shockable rhythm in a witnessed and monitored setting and the defibrillator is immediately available and they were previously well perfused and oxygentated pre-arrest then the use of 3 stacked shocks may be considered.

This situation is rare and may occur in the pre-hospital setting, emergency departments, critical care and coronary care units, and possibly also in the operating room. In these settings it may be appropriate to use a 3 stacked-shock technique, especially where there may be a relative contraindication to external cardiac compressions (e.g. after cardiac surgery).

The “3 stacked-shock sequence” can be optimized by immediate rhythm analysis and charging of the defibrillator. This sequence may be of benefit in scenarios where the time required for rhythm recognition and for recharging the defibrillator is short (ie:. <10 seconds). In these situations, such as in-hospital arrests, it would be expected to deliver the sequence of shocks (up to three) in no more than 30 seconds.

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Attitudes to oxygen administration are changing as new research is conducted calling into question the safety of oxygen in patients who are not hypoxic. Accordingly many organisations are reviewing their recommendations as to the use of oxygen and a number of guidelines in this regard have been published.

The Australian Resuscitation Council has reviewed oxygen administration at a number of levels. At a first responder/first aid level the current ARC Guideline 10.4 remains appropriate with no significant change required.

At an ALS level the role of oxygen in acute coronary syndrome (ACS) has already been addressed. The ACS Guideline states; “Supplemental oxygen should be initiated if the patient has breathlessness, hypoxaemia, signs of heart failure or shock. There is relatively limited evidence from clinical studies to support the routine use of oxygen therapy in ACS. The use of oxygen saturation monitoring by non-invasive techniques such as pulse oximetry, may be very useful in guiding oxygen therapy. However it is important to understand that hyperoxaemia may be potentially harmful in uncomplicated myocardial infarction”.

Whether the cautions about hyperoxaemia will prove to be applicable to all patients or just in specific patient groups such as ACS and possibly stroke remains to be demonstrated. In addition, there is a lack of consistency as to what value or range of values of oxygen saturation constitutes hypoxaemia.

The Australian Resuscitation Council clearly recommends that hypoxaemia should be avoided. However at this time there is insufficient evidence to clearly state a range of target oxygen saturation or enough clarity to recommend which patient groups the use of titrated oxygen should apply. The ARC will continue to monitor the research and revise its guidelines where the evidence becomes available to support recommendations on targeted oxygen therapy.
In relation to newborn infants, for specific guidelines about use of oxygen and for recommended target saturations, please see Guideline 13.4, Airway Management and Mask Ventilation of the Newborn Infant, pages 10-11.

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The available published data reveals conflicting evidence of benefit vs no benefit for compression only CPR. Strategies to improve the number of cardiac arrest patients’ receiving bystander should be encouraged but not to the abandonment of conventional CPR. Compression only CPR should be viewed as the first resuscitation step which should be followed as soon as possible by rescue breathing and other basic life support interventions.

The Australian Resuscitation Council continues to hold the view that any attempt at resuscitation is better than no attempt, and if rescuers are unwilling or unable to do rescue breathing they should do chest compressions only. If chest compressions only are given, they should be continuous at a rate of approximately 100/min

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When is it OK to use a tourniquet?

When attempts at direct pressure have failed to control limb haemorrhage and the bleeding is life- threatening.

What should be used?

Generally a purpose made tourniquet (at least as wide as a belt) should be used. In life threatening situations, improvising may be required. Tourniquets may cause or increase tissue injury which can make subsequent limb surgery difficult, so their use should be limited to life-threatening limb haemorrhage. Furthermore, the high-pressure required to control haemorrhage with a narrow tourniquet is associated with increased tissue damage and may lead to an amputation at a higher level.

In a first aid setting an improvised tourniquet should only be used where direct pressure limb haemorrhage control is failing and the victim’s life is at risk: by using a tourniquet the rescuer is making a conscious decision to risk the limb to save the victim’s life.

It would be incorrect to say that a tourniquet should never be used, however tourniquets should only be considered in extremely serious situations such as those described above and considering that tourniquet use presents considerable risk to the long-term viability and function of the limb

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What is the role of feeling for a pulse?
The assessment of a pulse is also controversial. This issue has previously been discussed in detail. It is reasonable for practitioners taught to feel a pulse to do so as part of the assessment for signs of life, but to limit the total time taken to 10 seconds.

Why is a single shock technique being advocated?
The default defibrillation technique is now to use a single shock technique rather than a salvo of up to three shocks. The main rationale for this approach is to minimise the interruptions to CPR, which have been shown to be associated with a rapidly decreasing diastolic blood pressure (and coronary perfusion pressure) and a decreased likelihood of successful defibrillation. The shock success for currently used defibrillators is actually very high for the initial shock, and the interruptions to CPR for the
second and third shocks in succession are thought in most circumstances to be more detrimental than the incremental success from these subsequent shocks.

For what specific circumstances is the three-shock strategy being retained?
Three Stacked Shocks were removed from the standard ALS algorithm as part of the 2010 CoSTR changes. It is now included under the special circumstances in resuscitation guideline.

Where a patient with a perfusing rhythm develops a shockable rhythm in a witnessed and monitored setting and the defibrillator is immediately available and they were previously well perfused and oxygentated pre-arrest then the use of 3 stacked shocks may be considered.

This situation is rare and may occur in the pre-hospital setting, emergency departments, critical care and coronary care units, and possibly also in the operating room. In these settings it may be appropriate to use a 3 stacked-shock technique, especially where there may be a relative contraindication to external cardiac compressions (e.g. after cardiac surgery).

The “3 stacked-shock sequence” can be optimized by immediate rhythm analysis and charging of the defibrillator. This sequence may be of benefit in scenarios where the time required for rhythm recognition and for recharging the defibrillator is short (ie:. <10 seconds). In these situations, such as in-hospital arrests, it would be expected to deliver the sequence of shocks (up to three) in no more than 30 seconds.

Why not assess for a rhythm and a pulse immediately after defibrillation?
The recommendation to immediately start CPR after a shock is based on the fact that the chance of developing a rhythm associated with an output in the first minute or so after defibrillation is extremely small. Starting CPR immediately after defibrillation, irrespective of the electrical success or otherwise, or the attempt at defibrillation, restores blood flow to the brain and heart and creates an environment more conducive to return of spontaneous circulation. A period of at least 1-2 minutes of good CPR appears to be able to increase the likelihood of success of the next attempt at defibrillation. Obviously there is no need for CPR to continue if signs of life return.

What is the exact protocol that should be followed for a persistent shockable rhythm?
The optimal sequence of events that should follow for a persistent shockable rhythm is not known. The sequence cannot be prescribed exactly but the general principles that should be followed are listed here.

  • At all times, interruptions to compressions should be minimised.
  • After an unsuccessful attempt at defibrillation a 2-minute period of CPR is recommended before the rhythm is reassessed.
  • If when the rhythm is reassessed a shockable rhythm persists, repeat defibrillation (second shock).
  • After the second attempt at defibrillation on recommencing chest compressions administer 1 mg adrenaline, continue CPR for 2 minutes and then reassess and repeat defibrillation if indicated (third shock).
  • Adrenaline should subsequently be administered at a rate of 1 mg approximately every three minutes until Return of Spontaneous Circulation. For simplicity, adrenaline could be administered in alternate loops. A period of at least 1-2 minutes of good CPR is recommended after each dose of adrenaline to help circulate the drug.
  • If the subsequent attempt at defibrillation is also unsuccessful, a 2-minute period of CPR is again recommended before the rhythm is reassessed.
  • If VF is still present after the administration of adrenaline and one further shock, consider administration of an anti-arrhythmic before defibrillation (fourth shock).
  • At any stage if a rhythm is present that should be associated with a pulse, then formal checking for signs of life (including a pulse check) should be performed. If there are no signs of life (including a pulse) then the non-shockable sequence should be followed.

What about the new devices that evaluate CPR quality or the VF waveform?
New devices that evaluate quality of CPR and the defibrillation waveform offer promise in the management of cardiac arrests, but at this stage they need further study before any recommendations can be made.

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ANZCOR supports and follows the international, evidence based, ILCOR 2015 Consensus on Science and Treatment Recommendations (CoSTR) regarding immobilisation of victims with suspected spinal injury, which are to recommend against the use of semi-rigid (SR) cervical collars by first aid providers. The ILCOR recommendation, and as such, the ANZCOR recommendation takes into account both the lack of evidence of benefit, and the risk of harm. The ILCOR and ANZCOR guidelines are specifically applied to first aid providers, however the evidence against the use of SR collars applies equally to other pre-hospital users of SR collars. Therefore the 2016 ANZCOR guideline recommends that these other groups involved in pre-hospital care also review their management of suspected spinal injury, in regards to the use of SR collars.

Ideally, the recommendation for first aiders to manage victims with suspected spinal injury using manual techniques rather than with a SR collar would be part of a system wide approach, with every provider in the chain of care acting consistently, within an agreed management framework.

In recommending against the use of SR collars by first aiders, ANZCOR is not lowering the expectation of the victim needing the highest level of spinal care, nor implying that spinal care is unnecessary. Based on the evidence to date and international consensus, ANZCOR’s position on the best management for victims with suspected spinal injury is that victims should have:

  • Immediate recognition of the potential for spinal injury
  • Minimal movement and handling of victim
  • Immediate assessment of the victim (DRSABC)
  • Immediate spinal care with manual techniques
  • Early transfer for definitive assessment and care

The evidence available to date, and international consensus opinion, suggests that these initiatives, not the physical application of a device such as a SR collar, are what lead to the best outcomes for the victims of spinal injury.

MAY 2016

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The Australian Resuscitation Council (ARC) has guidelines and flow charts specific to basic life support and the management of a drowned victim. We recommend that these be used for all teaching to the lay public and for all pool signage resuscitation charts that are to be read and used as training and public incident management prompts. As the nationally recognized peak body in resuscitation, made up of representatives of many national resuscitation and aquatic rescue organizations, we would recommend for Australia wide consistency of training and practice.

The ARC believes that the most effective way to encourage bystander resuscitation in the event of any cardiac arrest either due to drowning or another precipitant, is to have simple resuscitation steps that are standard, and interchangeable regardless of the cause, and regardless of the age of the victim.

In drowning, the ARC believes that resuscitation by a member of the lay public should be performed in accordance with the Basic Life Support guidelines as published on its website. This is in line with the practice supported by resuscitation councils around the world, including the European Resuscitation Council and American Heart Association. It is also the recommendation of the International Life Saving Federation.

In a drowning resuscitation, it is important that the victim receives rescue breaths, not just chest compression resuscitation. There is no evidence to support nor refute the order of commencing the resuscitation. As such, to keep the learning simplified, and aid memory retention by a lay provider who would be an infrequent performer of resuscitation, the ARC recommends starting drowning resuscitation with the chest compressions, as in any other resuscitation, followed by the rescue breaths.

In the most recent revision of the ARC guideline Management of a Drowned Victim, the assessment of the victim’s airway and assessment of breathing is done with the victim lying face up. This brought Australia into line with other international aquatic rescue organizations and the International Life Saving Federation. Only if the airway is found to need immediate clearing, is the victim rolled onto the side. Assessing the victim is a face up position aids visualization of the airway and assessment of breathing. It also means that resuscitation can commence earlier in a victim with a clear airway as unnecessary rolling onto the side and back is avoided.

The Queensland Government’s Department of Housing and Public Works has a requirement, documented in chapter 8 of the Building Act, that all pools display a CPR sign that must show how to perform CPR as per a flow sequence on the following weblink: http://www.hpw.qld.gov.au/construction/BuildingPlumbing/PoolSafety/Pages/RequirementsCPRwarningSigns.aspx  (accessed 22/09/2016).

The 7 step resuscitation sequence displayed on this web link and mandated in Queensland is not compliant with the Australian Resuscitation Council guidelines, firstly because it recommends rolling and assessing all victims onto their side, regardless of the need for airway clearance, and secondly because the Queensland requirement is to display pool signage that starts resuscitation with rescue breathing rather than chest compressions.

As well as believing that the Queensland mandate for a different resuscitation of a drowned victim will confuse the lay provider and possibly lead to a reluctance to start any resuscitation, The Australian Resuscitation Council believes that having one state in Australia promoting and enforcing resuscitation that is different from everywhere else in the country causes difficulties in teaching and resource production for many of the national rescue and resuscitation training organizations.

The Australian Resuscitation Council continues to work with the Queensland Government and Queensland resuscitation organizations to standardize guidelines across the country.

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While many resuscitations take place at bed height the majority of resuscitations in the community occur on the floor, it is common practice to demonstrate and teach resuscitation on the floor.

Some individuals who would in all probability get down on the floor in an emergency are reluctant to do so in practice, often because of difficulty getting up and joint pains.

The ARC notes that assessment requirements for the health training package currently recommends that CPR must be demonstrated on the floor in order to deem a student competent but takes the view that this specific location is not necessary in order to demonstrate competence in the skill of CPR.

The ARC specifies that learners must be able to physically demonstrate CPR skills and knowledge on a manikin. It does not specify that CPR must be demonstrated on the floor.

November 2016

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