The Australian Resuscitation Council, in co-operation with the New Zealand Resuscitation Council have at last published their local take on the recently released ILCOR 2015 guideline update for adult, paediatric and neonatal basic and advanced resuscitation. Released in mid January, the combined Australian and New Zealand update makes recommendations for how resuscitation should be conducted here based on the evidence and guidelines issued by the central body, ILCOR.

You can read my summary of the European Resuscitation Council interpretation of the ILCOR 2015 update as it pertains to motorsport here: ILCOR 2015 - Does it matter for motorsports? And if you go no further you will pretty much have the Australian guidelines covered.

As with the ERC guidelines, anyone who keeps themselves up to date on resuscitation literature will find nothing terribly mind blowing. The ARC guidelines however, come over a bit woolier than the AHA or ERC sets, and are far briefer (which might be a mercy).

You can find the core changes outlined in the ARC Executive Summary documents.

The individual BLS and ALS sections, which go through the individual elements along with the recomendations and levels of evidence, are here: The ARC Guidelines.

It is important to be aware that the evidence base for the majority of the recommendations is of low or very low quality and rests largely on observational studies and expert opinion. Only 1% of the recommendations are backed up by randomised control trials. This may be part of why the recommendations feel so vague as it may be an intelligent way of saying "this is the best that we've got, so we are not going to paint you into a medicolegal corner by stating that you must absolutely adhere to these guidelines."

These guidelines are largely written with medical causes of cardiac arrest in mind. Trauma and traumatic cardiac arrest is a different beast and there has been an evolution in management over the past 10 years. Still, from a motorsports response perspective there are a couple of ARC 2016 items worth taking note of. Taking cue from the ILCOR guidelines, the ARC has also recognised the occurrence of resuscitation is special circumstances, including sudden cardiac death in athletes and a few items of trauma. So here are some of the notable mentions.


Recognise that someone is unconcious and not breathing normally, check for danger, call for help and start CPR. Although they still promote the DRS.ABC.D mnemonic, the A and B component is simply a check and compression is still advocated to be started first with rescue breaths to be given after each round of chest compressions. So if you are using the DR.SCAB.D mnemonic, stick with it; they are essentially the same.

It's still a 30:2 ration of compressions to rescue breaths and while compression-only is preferable to nothing at all, they'd rather that rescue breaths are given if you are willing and able. Compress at a rate between 100 and 120 bpm (Using a metronome app may help).

In the ILCOR update there is a recommendation that chest compression depth be greater than 5cm for improved efficacy and outcome but less than 6cm to avoid excessive injury. The ARC guidelines have taken a more practical approach, recognising that targeting such a small window is likely to be difficult. So the ARC guidelines are sticking with "one third the diameter of the chest" which approximates 5cm in an adult and 4-5cm in a child.

Get an AED on.

Many of you may be aware of the GoodSAM app, released by a few of the London HEMS guys, which allows responders to alert nearby providers of a person in need of BLS resuscitation. Recently they updated the app to include a video feed that allows the dispatcher to see what the rescuer is up to and potentially provide guidance. While not specifically referenced in the ARC 2016 update, they do state that evidence of improved outcomes for this particular facility is equivocal (Guideline 11.6 section 4.1).


No big surprises here. The flowchart stays more or less the same. There is a recognition of the lack of evidence that most if not all of the traditional resuscitation drugs (adrenalin, calcium, bicarbonate, lignocaine) do little beyond improving survival to hospital admission. Survival to hospital discharge and, more importantly with good neurological outcome, so far has seemed to elude these medications. That said, perhaps that is all they will ever do and it is up to us (or clever researchers) to work out what better interventions to apply once the person has survived to get to the ED.

From that perspective there is increased recognition of the role of ultrasound in identifying reversible causes, the potential (though not routine) use of automated compression devices for prolonged or difficult access CPR (e.g in the back of an ambulance or in the cath lab) and the potential role of ECMO-CPR (eCPR) in centres where the expertise and resources exist to pursue it.

As long as the airway patency is maintained and assisted ventilation is performed during ALS, whether ventilation is given via a mask, a supraglottic airway (SGA) or formal intubation with an ETT is left to user discretion. Any advantage of the ETT as a medication route is made largely obselete by the availability of intraosseus (IO) devices.


Here's where things get a bit interesting. Previously EMST/ATLS ran trauma and ACLS ran medical arrests. In the 2016 ARC guidelines, similar to ILCOR 2015, we now see a blurring of those lines with some interesting results.

The semi-rigid c-spine has been toppled from its lofty position alongside airway interventions (Guideline 9.1.6.). There is a clear statement that the evidence of benefit for routine placement of the semi rigid collar is thin at best, while the evidence of harm is harder to ignore. So we are advised that a concious patient "with significant spinal pain will likely have muscle spasm which acts to splint their injury" and that while it is important to maintain the neck of an unconcious patient a neutral position, the "use of semi rigid (SR) cervical collars by first aid providers is not recommended (CoSTR 2015, weak recommendation, low quality evidence)."

So it would seem that the next time you are responded to a race incident with the suspicion of a neck injury, at least by mechanism, the application of a semi-rigid c-spine collar is no longer mandatory. Instead we can exercise discretionary judgement as to whether to let the person self extricate, self extricate with a collar in place or be assisted out with careful manual in-line c-spine control.

It will be interesting to see how long it takes for medical response plans to adjust their approach.

The rigid spine board takes a hit too. While it still has a role in assisting extrication or moving a person, leaving them strapped to the board for prolonged periods is no longer acceptable. Especially when better options exist such as spinal transport rated ambulance trolleys and bean-filled vacuum matresses.

And that's where the trauma excitement ends. You won't find the traumatic cardiac arrest algorithm that is in the ERC 2015 guidelines, which is a pity. It just about gets a mention in Guideline 11.10 under pericardial tamponade. The first aid response recommendations for burns and head injury won't set your world on fire either and there is no mention of concussion at all.

The cardiac arrest in special situations is again a cue taken from the ILCOR update, but there is little here for motorsport unless you regularly come across pregnant asthmatics having trouble with anaphylaxis due to envenomation after being buried under an avalanche. There is brief mention of sudden cardiac death and arrythmic syncope with some risk factors to look out for. After that standard ALS management is advised with transport to a specialist centre assuming they survive.

So, in summary:
  • BLS and ALS are firmed up but relatively unchanged overall.
  • The drugs might work for short term goals of transport to hospital but probably not beyond. 
  • Automated chest compression devices are an option but not mandated, especially if there is a good enough human present.
  • Choose your own preferred airway maintenance device during CPR - BVM / SGA / ETT
  • Mandatory use of semi-rigid c-spine collars and indefinite strapping to rigid back boards are out.
  • Diagnostic ultrasound is in.
  • There is a traumatic cardiac arrest algorithm in the ERC guidelines update but not the ARC.
  • Head injury, threshold burns and arrythmic syncope / aborted SCD get sent to specialists
 And that's about it.

Comments as always below.

Addendum (24th June 2016)

In April 2016 ANZCOR added a further update to its resuscitation guidelines which specifically deals with Traumatic Cardiac Arrest. While there is no management flowchart, there is a fairly detailed description of the stance and evidence recommended by ANZCOR for the various components of Traumatic Cardiac Arrest management, including the role of external chest compressions, defibrillation, blood volume replacement, chest decompression and resuscitative thoracotomy, amongst others.

There is also a clear statement that "No fault should be attributed to clinicians who, by remaining within their scope of practice, do not perform one of the procedures this guideline recommends or lists for consideration."

The full details are in Guideline 11-10-1 Management of Cardiac Arrest due to Trauma