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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Cardiac sudden death &#40;CSD&#41; affects about 350&#44;000&#8211;700&#44;000 individuals each year in Europe&#44; and 25&#8211;30&#37; of the victims present ventricular fibrillation &#40;VF&#41; as initial manifesting rhythm&#46; Probably many more patients have rhythms amenable to defibrillation &#40;DF&#41; at the time of cardiac arrest&#44; but in many cases when the Medical Emergency Service &#40;MES&#41; teams monitor the electrocardiogram &#40;ECG&#41;&#44; the rhythm has deteriorated to asystolia&#46; If the rhythm is registered immediately affect arrest&#44; the proportion of victims with VF would be 59&#8211;65&#37;&#46; The treatment for cardiac arrest due to VF is immediate cardiopulmonary resuscitation &#40;CPR&#41; by witnesses &#40;chest compressions combined with rescue breathing&#41; and early defibrillation&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Most cases of cardiac arrest of non-cardiac origin are due to respiratory causes such as drowning&#44; particularly in children&#44; and asphyxia&#46; According to the World Health Organization &#40;WHO&#41;&#44; in many parts of the world drowning is the main cause of death &#40;<a href="http://www.who.int/water_sanitation_health/diseases/drowning/in/">http&#58;&#47;&#47;www&#46;who&#46;int&#47;water&#95;sanitation&#95;health&#47;diseases&#47;drowning&#47;in&#47;</a>&#41;&#59; as a result&#44; rescue breathing is perhaps more determinant for resuscitation of the victims&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In most communities&#44; the time taken by the MES team in reaching the site of arrest is 8<span class="elsevierStyleHsp" style=""></span>min&#44; versus 11<span class="elsevierStyleHsp" style=""></span>min for the first defibrillator discharge&#46; Patient survival therefore depends on the start of BLS by the witnesses of the event and the use of an automated external defibrillator &#40;AED&#41; for defibrillation&#44; where available&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The results of the latest international consensus conference of the International Liaison Committee on Resuscitation &#40;ILCOR&#41; held in Dallas in February 2010&#44; and its conclusions&#44; published in October&#44; conform the Guides 2010 on resuscitation&#46; The present study describes the principal aspects of BLS and AED&#44; as well as the novelties from the mentioned conference&#44; published by the European Resuscitation Council &#40;ERC&#41;&#46;</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">The chain of survival</span><p id="par0025" class="elsevierStylePara elsevierViewall">The actions linking the cardiac arrest victim to survival is known as the chain of survival&#44; which summarizes the vital steps required for successful resuscitation&#46; These steps or actions include early recognition of the emergency situation and activation of the MES&#44; early CPR&#44; early defibrillation and advanced life support &#40;ALS&#41;&#44; together with care after resuscitation if the victim recovers from cardiac arrest&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The importance of recognizing the critical situation and&#47;or heart attack&#44; and of avoiding cardiac arrest&#44; as well as of the care following resuscitation&#44; is underscored by the inclusion of these elements in the four-link chain of survival&#46; The first link indicates the importance of recognizing individuals at risk of cardiac arrest&#44; and of calling for help in the hope that rapid patient care can avoid the arrest&#46; The central links of this chain in turn define the integration of CPR and defibrillation as the key components in early resuscitation&#44; in an attempt to restore life&#46; The end link&#44; advanced life support and effective treatment posterior to resuscitation&#44; focuses on the preservation of the vital signs of the patient &#8211; particularly referred to the heart and brain&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Description of the links in the chain of survival &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0040" class="elsevierStylePara elsevierViewall">As has been commented&#44; the first link in the chain is alerting the MES after recognizing the situation of cardiac arrest&#46; The number dialed is the same throughout Europe&#58; 112&#46; The alerting person must identify himself&#44; clearly explain what is happening to the patient&#44; identify the precise location&#44; and indicate whether CPR maneuvers will be started&#46; The indications of the dispatcher are to be followed&#44; and the latter must always be the last to hang up&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0045" class="elsevierStylePara elsevierViewall">The second link is basic CPR by the persons witnessing the arrest&#46; High-quality CPR can double or even triplicate survival&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0050" class="elsevierStylePara elsevierViewall">The third link in the chain is defibrillation&#44; which should take place as soon as possible&#46; In effect&#44; defibrillation is a key element in the chain of survival&#44; and is one of the few interventions to have been shown to improve the outcome of cardiac arrest with VF&#46; Since the effectiveness of the discharges quickly decreases with passing time&#44; defibrillation ideally should be carried out before the arrival of the MES &#8211; the average response time of the latter being no less than 8&#8211;10 min&#46; In this context&#44; AED are safe and effective when used by laypersons&#46; Thus&#44; ideally the first intervening person &#40;witness&#44; trained volunteer&#44; fireman&#44; policeman&#44; etc&#46;&#41; should be able to use an AED&#44; and the latter should be available in the first 3&#8211;5<span class="elsevierStyleHsp" style=""></span>min of arrest&#46; The new recommendations advocate the installation of AEDs in particularly busy public places&#44; and stress the importance of public access to defibrillation programs&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#46;</span><p id="par0055" class="elsevierStylePara elsevierViewall">The fourth and final link in the chain is represented by ALS and patient care after resuscitation&#46;</p></li></ul></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Prevention of arrest and early detection of the warning signs of potential sudden death</span><p id="par0060" class="elsevierStylePara elsevierViewall">Acute coronary syndrome &#40;ACS&#41; is the most common cause of cardiac sudden death&#46; Recognition of the cardiac origin of chest pain is very important&#44; since the probability of cardiac arrest secondary to acute myocardial ischemia is at least 21&#8211;33&#37; in the first hour after symptoms onset&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> The telephone call dialing 112 to activate the MES must be made as soon as the first symptoms are identified&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Recognizing cardiorespiratory arrest</span><p id="par0065" class="elsevierStylePara elsevierViewall">In many cases&#44; even for healthcare professionals&#44; it proves difficult to determine whether an unconscious person is in a state of cardiac arrest&#46; Healthcare professionals&#44; in the same way as laypersons performing resuscitation&#44; have difficulties determining the presence or absence of normal breathing in unresponsive victims&#44; since either the airway is not open&#44; or the patient is gasping&#46; In this context&#44; gasping is present in up to 40&#37; of all cases of cardiac arrest and in the first minutes&#44; and survival is favored when gasping is recognized as a sign of cardiac arrest&#46; Laypersons therefore should be instructed to start CPR if the victim is unconscious and fails to respond or does not breathe normally&#46; Adequate description of the condition of the patient is extremely important when calling the MES&#46; It is very important for the telephone operator or dispatcher to receive information on the breathing of the patient from the person who is calling&#46; Precision in the identification of cardiac arrest on the part of the telephone operators varies considerably&#46; If the operator adequately recognizes the situation&#44; appropriate measures can be taken&#44; such as CPR by witnesses under telephone guidance&#44; and the advanced life support units can ensure an adequate response&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Training of the dispatchers of out-hospital emergency services</span><p id="par0070" class="elsevierStylePara elsevierViewall">The telephone operators or dispatchers receiving the emergency calls must be trained through strict protocols in obtaining relevant information from the calling person&#46; This information is based on the recognition of the absence of response and on evaluation of the quality of breathing of the victim&#46; In the presence of a patient who fails to respond and does not breathe normally&#44; a suspected cardiorespiratory arrest &#40;CRA&#41; protocol should be activated immediately&#46; Gasping and short and noisy breathing on the part of the victim are not to be confused with normal breathing&#46; Gasping is present in 40&#37; of the cases in the first minutes of CRA&#44; and patient survival is improved when it is recognized as a sign of arrest&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Likewise&#44; the dispatchers must be trained to guide the calling person by telephone to perform CPR with chest compressions only&#46; Performing CPR only with compressions is better than performing no CPR maneuvers&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> When the calling person has no training in CPR&#44; the telephone operator should insist on the application of chest compressions until the MES arrives&#46; In the first minutes of CRA of cardiac origin&#44; the blood does not suffer important oxygen desaturation&#44; and compressions are a priority concern to ensure a minimum blood flow to the brain and myocardium&#44; with a view to maintaining sensitivity to defibrillation &#8211; increasing the chances for restored cardiac rhythm with an effective beat after defibrillation&#46; For every minute of delay in applying defibrillation&#44; survival following VF decreases 10&#8211;12&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a> It the person witnessing CRA performs CPR&#44; the decrease is only 3&#8211;4&#37;&#47;min&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#8211;10</span></a> Immediate CPR performed by witnesses on scene can double or even triple survival in cardiac arrest with VF&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">High-quality CPR</span><p id="par0075" class="elsevierStylePara elsevierViewall">The new recommendations underscore the importance of quality cardiac massage as a determinant factor for survival at hospital discharge among patients who have suffered cardiac arrest&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Cardiac massage</span><p id="par0080" class="elsevierStylePara elsevierViewall">Cardiac massage should be performed as follows&#58; the resuscitating person is to position himself alongside the victim and place the base of the palm of the hand on the center of the chest of the patient&#46; The base of the other hand is then placed parallel over that of the first&#44; intercrossing the fingers of both hands&#44; and compressing the chest of the patient with both arms extended and vertical &#8211; depressing the sternum at least 5<span class="elsevierStyleHsp" style=""></span>cm but no more than 6<span class="elsevierStyleHsp" style=""></span>cm&#46; The pressure is then relaxed completely to allow the chest of the patient to expand&#44; but without removing the hands from the chest&#46; The compression maneuvers are to be performed at a rate of between 100 and 120&#47;min&#46; The compressions and decompressions should have the same duration&#46; If the resuscitating person is able to do so&#44; two rescue breathings should be interspaced with a sequence of 30 compressions&#47;two ventilations&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">As a result of a lack of strength&#44; out of fear of causing injury&#44; and particularly due to fatigue&#44; some resuscitators compress the chest less deeply than indicated&#46; There is documented evidence that a minimum compression of 5<span class="elsevierStyleHsp" style=""></span>cm results in a greater rate of spontaneous circulatory recovery &#40;SCR&#41; than compression with a depth of 4<span class="elsevierStyleHsp" style=""></span>cm or less&#46; Damage produced by cardiac massage has not been shown to be directly related to the depth of chest compression&#44; and there are no studies indicating a limit to the depth of compression&#59; in any case&#44; however&#44; a depth of 6<span class="elsevierStyleHsp" style=""></span>cm should not be exceeded&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Rescue breathing</span><p id="par0090" class="elsevierStylePara elsevierViewall">In order to be effective&#44; rescue breathing should be carried out as follows&#58; the resuscitating person should open the patient airway by means of the forehead-chin maneuver&#44; clamping the nose with the thumb and index finger of the hand placed on the forehead and&#44; after a normal inspiration&#44; should insufflate air into the mouth of the patient&#44; using the lips to seal the mouth&#44; while confirming the rising chest of the victim&#46; The resuscitator then should draw back from the patient&#44; breathe in again&#44; and repeat the maneuver once the air has passively emerged from the chest of the patient&#46; Two respirations should be made in 5<span class="elsevierStyleHsp" style=""></span>s&#46; Immediately afterwards&#44; another sequence of 30 compressions should be started&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">CPR only with compressions</span><p id="par0095" class="elsevierStylePara elsevierViewall">Witnesses of a cardiac arrest who have had no training in CPR can perform cardiac massage alone&#44; following the real-time indications of a trained dispatcher&#46; In this case uninterrupted chest compressions are indicated at a rate of at least 100&#47;min&#44; but no more than 120&#47;min&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Lastly&#44; feedback for the resuscitating person is important to guarantee quality CPR&#46; During resuscitation&#44; devices can be used allowing immediate warning&#47;feedback&#46; The data recorded by the resuscitation equipment can also be used for resuscitation quality control&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Elimination of a predetermined period of CRP before defibrillation in out-hospital arrest not witnessed by the MES</span><p id="par0105" class="elsevierStylePara elsevierViewall">Different studies have demonstrated the beneficial impact of immediate CPR upon patient survival&#44; and the negative consequences of a delay in defibrillation&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;11&#44;13</span></a> Other studies have analyzed the convenience of applying a period of CPR before starting defibrillation in non-evidenced cardiac arrest&#44; or in those cases where some time has elapsed until the start of CPR&#46; Review of the evidence for the 2005 guides resulted in the recommendation for the MES to perform 2<span class="elsevierStyleHsp" style=""></span>min &#40;5 cycles of 30&#58;2&#41; of CPR before defibrillation in cases of prolonged arrest &#40;over 5<span class="elsevierStyleHsp" style=""></span>min&#41;&#46; The studies presented were carried out in arrests in which the time to response exceeded 4&#8211;5<span class="elsevierStyleHsp" style=""></span>min&#44; and in which the paramedics or physicians of the MES performed 1&#46;5&#8211;3<span class="elsevierStyleHsp" style=""></span>min of CPR before defibrillation&#46; This protocol improved SCR as well as survival at hospital discharge<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;15</span></a> and after 1 year in patients with out-hospital VF&#44; compared with the cases in which immediate defibrillation was carried out&#46; In two randomized&#44; controlled trials&#44; a period of 1&#46;5&#8211;3<span class="elsevierStyleHsp" style=""></span>min of CPR before defibrillation&#44; performed by the MES personnel&#44; did not improve either SCR or survival at discharge in VF&#44; independently of the response time of the MES&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;17</span></a> Other studies likewise have failed to demonstrate improvements in SCR or survival at discharge with initial CPR&#44;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a> although one reported a more favorable neurological prognosis 30 days and 1 year after arrest&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">There is scientific evidence that cardiac massage while placing the electrodes and loading the AED improves patient survival&#46; Therefore&#44; the MES team should perform CPR while the AED is being prepared&#44; the electrodes are placed on the patient&#44; and the device is being charged&#44; with a view to minimizing the interruption of chest compressions&#46; However&#44; the new recommendations do not specify a concrete duration of CRP &#40;2&#8211;3<span class="elsevierStyleHsp" style=""></span>min&#41; before analyzing cardiac rhythm and administering a discharge&#44; where indicated&#46; If some MES&#44; following the 2005 indications&#44; apply a certain duration of chest compressions before defibrillation&#44; they may continue with this practice&#44; in view of the lack of conclusive data indicating the need for changes in this sense&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Maintenance of cardiac massage while loading the AED</span><p id="par0115" class="elsevierStylePara elsevierViewall">Warranted by the scientific evidence&#44; the new recommendations underscore the importance of high-quality cardiac massage&#44; with the minimization of interruptions&#44; for improving patient survival&#46; Following these indications&#44; chest compression is to be continued while the AED is placed and used&#46; These defibrillators are safe and easy to use by laypersons&#44; and allow defibrillation of the patient before arrival of the MES&#46; Defibrillation technology advances quickly and now allows the evaluation of cardiac rhythm while CPR is performed&#44; and the resuscitating person can continue the chest compressions while the AED analyzes the rhythm and indicates the convenience or not of delivering a discharge&#46; In this way it is possible to minimize the time between interruption of the chest compressions and administration of the discharge &#40;pre-discharge pause&#41;&#46; A delay of only 5&#8211;10<span class="elsevierStyleHsp" style=""></span>s suffices to lessen the efficacy of defibrillation&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#8211;22</span></a> The pre-discharge pause can be reduced to less than 5<span class="elsevierStyleHsp" style=""></span>s if massaging is continued during loading of the AED&#44; and if the team is guided by an effective person&#46; Rigorous but rapid checking is required to ensure that nobody is in physical contact with the patient at the moment of the discharge&#46; The risk of someone on the resuscitating team receiving a discharge can be lessened if all members wear gloves during the intervention&#46; After defibrillation&#44; chest compression should be resumed immediately in order to reduce the post-discharge pause&#46; The entire process should be carried out without interrupting cardiac massage for more than 5<span class="elsevierStyleHsp" style=""></span>s&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Defibrillation is a key link in the chain of survival&#44; and one of the few interventions truly capable of improving survival in cardiac arrest due to VF&#46; The success of discharges decreases rapidly with passing time&#46; It is very difficult for defibrillation to be carried out by the MES in the first few minutes of arrest&#46; The intervention of trained volunteers has improved the outcome at hospital discharge&#44; and if defibrillation is carried out in the first 3<span class="elsevierStyleHsp" style=""></span>min of arrest&#44; the survival rate can reach 75&#37;&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">People trained in the use of the AED must be able to perform quality CPR until the MES arrives on scene&#46; The guides stress the importance of performing immediate CPR with high-quality compressions on an early and uninterrupted basis&#46; Compression should only be interrupted for as briefly as possible to perform ventilation&#44; analyze the cardiac rhythm or deliver a discharge&#44; and should be resumed immediately after defibrillation&#46; If two resuscitators are available&#44; one should prepare the AED&#44; position the electrodes on the naked chest of the patient and connect the defibrillator&#44; while the other should perform the chest compressions &#8211; interrupting them only to analyze the rhythm&#44; check that nobody is in contact with the patient&#44; and apply the discharge&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Sequence of BLS</span><p id="par0130" class="elsevierStylePara elsevierViewall">The sequence of maneuvers is described in <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Use of an AED</span><p id="par0135" class="elsevierStylePara elsevierViewall">AED are safe and effective&#44; even when used by laypersons&#44; and make it possible to apply defibrillation long before the arrival of professional help&#46; The resuscitators should continue CPR with minimum interruption of the chest compressions while the AED is being placed and during its use&#46; The resuscitators should follow the verbal instructions immediately&#44; and particularly must ensure the resumption of CPR&#46; The standard AED can be used with children over 8 years of age&#46; In the case of children between 1 and 8 years of age&#44; pediatric patches&#47;electrodes should be used&#44; together with an attenuator or pediatric operating mode&#44; if available&#46; If not available&#44; the AED should be used as is&#46; The use of these devices is not recommended in infants under 1 year of age&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Sequence of BLS and use of the AED</span><p id="par0140" class="elsevierStylePara elsevierViewall">The sequence of interventions is shown in <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Public access to defibrillation &#40;PAD&#41; programs</span><p id="par0145" class="elsevierStylePara elsevierViewall">Public access to defibrillation programs should be targeted to public places such as airports&#44; train or subway stations&#44; sports centers&#44; industrial centers&#44; commercial centers&#44; stadiums&#44; offices&#44; casinos and airplanes&#44; i&#46;e&#46;&#44; places where cardiac arrest can be witnesses and where trained resuscitators can quickly appear on scene&#46; PAD programs involving laypersons as resuscitators and with short response times&#44; using police personnel as first intervening persons&#44; have resulted in survival rates of between 49 and 74&#37;&#46; Accordingly&#44; PAD programs can only offer success if trained resuscitators and AEDs in sufficient number are available&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#44;21</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">However&#44; the great potential benefit of AEDs has not yet been materialized&#44; since these devices are generally located in public places&#44; and almost 80&#37; of all cardiac arrests occur in the home or in residential areas&#46; PAD programs and the use of AEDs by first intervening resuscitators can serve to increase the number of victims that receive CPR by witnesses&#44; and early defibrillation&#46; When developing such a program&#44; the community supervisors must assess factors such as adequate emplacement of the AED&#44; based on previous incidence or population concentration studies&#59; the training of a team in charge of monitoring and maintaining the devices&#59; the training of people who probably will use the AEDs&#59; and&#44; if possible&#44; identify those individual volunteers agreeing to use the device on the victims of cardiac arrest&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">The installation of AEDs in residential areas has not been studied to date&#44; and the acquisition of an AED for individual use in the home &#8211; even among individuals considered to be at high risk of cardiac arrest &#8211; has not been evaluated&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">In order for AED installation and the PAD program to offer maximum effectiveness&#44; the American Heart Association &#40;AHA&#41; has underscored the need to incorporate a series of elements<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a>&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">1&#46;</span><p id="par0165" class="elsevierStylePara elsevierViewall">Organization and planning of the response in the event of an emergency situation&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">2&#46;</span><p id="par0170" class="elsevierStylePara elsevierViewall">Training of the possible resuscitators both in handling of the AED and in applying CPR&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">3&#46;</span><p id="par0175" class="elsevierStylePara elsevierViewall">Connections to the local MES&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">4&#46;</span><p id="par0180" class="elsevierStylePara elsevierViewall">Establishment of a continued quality improvement process&#44; analyzing from adequate operation of the AEDs and the required electrodes to adequacy of the response system and competence of the resuscitators&#46;</p></li></ul></p><p id="par0185" class="elsevierStylePara elsevierViewall">It has been shown that places in which an AED has been located without all these elements are unlikely to improve survival among cardiac arrest patients&#44; since the mere presence of these devices does not mean that they will be used in the event of need&#44; or that they will be used correctly&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">ILCOR universal AED sign</span><p id="par0190" class="elsevierStylePara elsevierViewall">The ILCOR has unanimously approved the suggestion by its work group to adopt a universal sign indicating the presence of an AED&#46; The sign has been designed according to the ISO 7010 norm for safety signs and models&#46; The colors and symbols in turn comply with the ISO 3864-3 norm&#44; and its interpretability has been confirmed according to the ISO 9186-1&#44; rev&#46; 2007 norm&#44; proving to be superior to other designs&#46; The AED sign &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41; aims to indicate the presence of the device&#44; its location in any room or container&#44; for both public use and to indicate the direction in which to go in order to reach it&#46; The sign should serve to quickly identify an AED in a public place for immediate use on a cardiac arrest victim&#46; To this effect&#44; the AED can be combined with other symbols such as an arrow&#46; The sign can also be accompanied by the letters &#8220;AED&#8221;&#44; or the equivalent in other languages&#46; The full term &#8220;defibrillator&#8221; &#40;or equivalent&#41; is not recommended&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0195" class="elsevierStylePara elsevierViewall">It is the aim of the ILCOR to have this sign approved throughout the world by the respective national resuscitation councils&#46; The sign also must be approved by all AED manufacturers for use with their products&#44; and by the signaling industry&#46; The different public organizations and governments in turn should promote the universal adoption of this AED sign&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">In this sense&#44; it is to be expected that this universal sign will enhance awareness of the existence of these devices and will contribute to their rapid incorporation in emergency situations in the form of cardiac arrest &#40;<a href="https://www.erc.edu/index.php/newsItem/in/nid=204/">https&#58;&#47;&#47;www&#46;erc&#46;edu&#47;index&#46;php&#47;newsItem&#47;in&#47;nid&#61;204&#47;</a>&#41;&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Summary of changes since the guides of 2005</span><p id="par0205" class="elsevierStylePara elsevierViewall">Lastly&#44; it should be mentioned that many of the recommendations of the European Resuscitation Council &#40;ERC&#41; Guides 2005 remain without change &#8211; either because no new studies have been published&#44; or because the new evidence available since 2005 has simply reinforced the already existing evidence&#46; Nevertheless&#44; the evidence published since 2005 does point to the need to incorporate changes to some parts of the new Guide 2010&#46; In summarized form&#44; the changes of 2010&#44; in relation to the Guides 2005&#44; referred to BLS and AED are the following<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8226;</span><p id="par0210" class="elsevierStylePara elsevierViewall">Emergency telephone operators must be trained to question people who call&#44; using strict protocols for obtaining information&#46; This information should center on recognizing a lack of patient response and on the quality of breathing&#46; In combination with the absence of response&#44; the absence of breathing or any other breathing anomaly should serve to activate the telephone operator protocol for suspected cardiac arrest&#46; The importance of gasping as a sign of cardiac arrest is underscored&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8226;</span><p id="par0215" class="elsevierStylePara elsevierViewall">All resuscitators&#44; whether trained or otherwise&#44; should perform chest compressions on victims of cardiac arrest&#46; It remains essential to stress the importance of high-quality chest compression&#46; The aim should be to compress to a depth of at least 5<span class="elsevierStyleHsp" style=""></span>cm&#44; with a frequency of at least 100<span class="elsevierStyleHsp" style=""></span>compressions&#47;min&#44; allowing full chest rebound&#44; and minimizing interruptions of chest compression&#46; Trained resuscitators also should perform ventilations with a compression&#47;ventilation ratio of 30&#58;2&#46; In the case of non-trained resuscitators&#44; CPR only with chest compressions guided by telephone is advocated&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">&#8226;</span><p id="par0220" class="elsevierStylePara elsevierViewall">Devices allowing interactive messages during CPR will offer resuscitators immediate feedback&#44; and their use is thus encouraged&#46; The data stored by the resuscitation equipment can be used to supervise and improve the quality of CPR&#44; and supply information to the professional resuscitators during the revision sessions&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">&#8226;</span><p id="par0225" class="elsevierStylePara elsevierViewall">These guides underscore the importance of performing early chest compressions without interruptions&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">&#8226;</span><p id="par0230" class="elsevierStylePara elsevierViewall">Much greater emphasis is now placed on the need to minimize the duration of the pauses before and after AED discharge&#59; continuation of chest compression during loading of the device is recommended&#44; with immediate resumption of compression after defibrillation&#46; The defibrillator discharge should be completed with no more than a 5-s interruption of the chest compressions&#46;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">&#8226;</span><p id="par0235" class="elsevierStylePara elsevierViewall">The safety of the resuscitator remains essential&#44; although these guides recognize that the risk of damage with a defibrillator is very small &#8211; particularly when gloves are worn&#46; Attention now focuses on rapid safety checking&#44; in order to minimize the pre-discharge pause&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">&#8226;</span><p id="par0240" class="elsevierStylePara elsevierViewall">In the case of cardiac arrest outside the hospital&#44; the MES personnel should provide quality CPR&#46; With the availability of a defibrillator&#44; the device should be placed and loaded&#44; although it is no longer recommended to systematically perform prior CPR&#44; e&#46;g&#46;&#44; for a period of 2 or 3<span class="elsevierStyleHsp" style=""></span>min&#44; before the analysis of cardiac rhythm and discharge&#46; If some MES have fully incorporated certain duration of chest compressions before defibrillation to their intervention protocol&#44; they may reasonably continue with this practice&#44; in view of the lack of conclusive data indicating the need for changes in this sense&#46;</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">&#8226;</span><p id="par0245" class="elsevierStylePara elsevierViewall">Increased development of the PAD programs is encouraged&#44; underscoring the need for an increased distribution of AEDs in both public and residential areas&#46;</p></li></ul></p></span></span></span>"
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          "titulo" => "Introduction"
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            0 => array:2 [
              "identificador" => "sec0010"
              "titulo" => "The chain of survival"
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            1 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Prevention of arrest and early detection of the warning signs of potential sudden death"
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            2 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Recognizing cardiorespiratory arrest"
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            3 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Training of the dispatchers of out-hospital emergency services"
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            4 => array:2 [
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              "titulo" => "High-quality CPR"
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              "titulo" => "Cardiac massage"
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              "titulo" => "Rescue breathing"
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              "titulo" => "CPR only with compressions"
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              "titulo" => "Elimination of a predetermined period of CRP before defibrillation in out-hospital arrest not witnessed by the MES"
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            9 => array:2 [
              "identificador" => "sec0055"
              "titulo" => "Maintenance of cardiac massage while loading the AED"
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            10 => array:2 [
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              "titulo" => "Sequence of BLS"
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            11 => array:2 [
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              "titulo" => "Sequence of BLS and use of the AED"
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              "titulo" => "Public access to defibrillation &#40;PAD&#41; programs"
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              "titulo" => "ILCOR universal AED sign"
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            15 => array:2 [
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              "titulo" => "Summary of changes since the guides of 2005"
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    "fechaRecibido" => "2011-03-06"
    "fechaAceptado" => "2011-03-10"
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          "clase" => "keyword"
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          "palabras" => array:6 [
            0 => "Cardiac arrest"
            1 => "Resuscitation"
            2 => "Basic life support"
            3 => "Defibrillation"
            4 => "Dispatcher"
            5 => "Public access"
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            0 => "Parada cardiaca"
            1 => "Resucitaci&#243;n"
            2 => "Soporte vital b&#225;sico"
            3 => "Desfibrilaci&#243;n"
            4 => "Operadores telef&#243;nicos"
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        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">During resuscitation&#44; basic life support &#40;BLS&#41; and automated external defibrillation refer to maneuvers designed to maintain airway patency and support breathing and circulation without equipment other than a barrier device and the use of an automated external defibrillator &#40;AED&#41;&#46; We present some of the most important developments incorporated into the new international recommendations for resuscitation 2010&#46; Aspects related to prevention and early detection of cardiac arrest are highlighted&#44; along with the important role of dispatchers of emergency medical services&#44; the importance of high quality CPR and programs of public access defibrillation&#46; We likewise describe sequences of action and basic life support algorithms&#44; and semi-automated external defibrillation&#46;</p>"
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        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Durante la resucitaci&#243;n&#44; el soporte vital b&#225;sico &#40;SVB&#41; y la desfibrilaci&#243;n externa autom&#225;tica hacen referencia a las maniobras de mantenimiento de la permeabilidad de la v&#237;a a&#233;rea&#44; el apoyo de la respiraci&#243;n y de la circulaci&#243;n&#44; sin el uso de otro equipo que un dispositivo de barrera&#44; y el uso de un desfibrilador externo autom&#225;tico &#40;DEA&#41;&#46; Se presentan a continuaci&#243;n algunas de las novedades m&#225;s importantes que incorporan las nuevas recomendaciones internacionales en resucitaci&#243;n de 2010&#46; Se destacan los aspectos relacionados con la prevenci&#243;n y detecci&#243;n precoz de la parada cardiaca&#44; el papel importante de los teleoperadores de los servicios de emergencias m&#233;dicas&#44; la importancia de la resucitaci&#243;n cardiopulmonar de alta calidad y de los programas de acceso p&#250;blico a la desfibrilaci&#243;n&#46; Se presentan las secuencias de actuaci&#243;n y algoritmos de soporte vital b&#225;sico y desfibrilaci&#243;n externa semiautom&#225;tica&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; L&#243;pez-Messa JB&#44; et al&#46; Novedades en soporte vital b&#225;sico y desfibrilaci&#243;n externa semiautom&#225;tica&#46; Med Intensiva&#46; 2011&#59;35&#58;299&#8211;306&#46;</p>"
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Update in Intensive Care Medicine: News in Resuscitation
News in basic life support and semi-automated external defibrillation
Novedades en soporte vital básico y desfibrilación externa semiautomática
J.B. López-Messaa,b,
Corresponding author
jlopezme@saludcastillayleon.es

Corresponding author.
, P. Herrero-Ansolaa,c, J.L. Pérez-Velaa,d, H. Martín-Hernándeza,e
a Comité Directivo PNRCP (SEMICYUC)
b Complejo Asistencial de Palencia, Palencia, Spain
c Servicio de Urgencias Médicas, SUMMA 112, Madrid, Spain
d Hospital 12 de Octubre, Madrid, Spain
e Hospital Galdakao-Usansolo, Galdácano, Vizcaya, Spain
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and early defibrillation&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Most cases of cardiac arrest of non-cardiac origin are due to respiratory causes such as drowning&#44; particularly in children&#44; and asphyxia&#46; According to the World Health Organization &#40;WHO&#41;&#44; in many parts of the world drowning is the main cause of death &#40;<a href="http://www.who.int/water_sanitation_health/diseases/drowning/in/">http&#58;&#47;&#47;www&#46;who&#46;int&#47;water&#95;sanitation&#95;health&#47;diseases&#47;drowning&#47;in&#47;</a>&#41;&#59; as a result&#44; rescue breathing is perhaps more determinant for resuscitation of the victims&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In most communities&#44; the time taken by the MES team in reaching the site of arrest is 8<span class="elsevierStyleHsp" style=""></span>min&#44; versus 11<span class="elsevierStyleHsp" style=""></span>min for the first defibrillator discharge&#46; Patient survival therefore depends on the start of BLS by the witnesses of the event and the use of an automated external defibrillator &#40;AED&#41; for defibrillation&#44; where available&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The results of the latest international consensus conference of the International Liaison Committee on Resuscitation &#40;ILCOR&#41; held in Dallas in February 2010&#44; and its conclusions&#44; published in October&#44; conform the Guides 2010 on resuscitation&#46; The present study describes the principal aspects of BLS and AED&#44; as well as the novelties from the mentioned conference&#44; published by the European Resuscitation Council &#40;ERC&#41;&#46;</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">The chain of survival</span><p id="par0025" class="elsevierStylePara elsevierViewall">The actions linking the cardiac arrest victim to survival is known as the chain of survival&#44; which summarizes the vital steps required for successful resuscitation&#46; These steps or actions include early recognition of the emergency situation and activation of the MES&#44; early CPR&#44; early defibrillation and advanced life support &#40;ALS&#41;&#44; together with care after resuscitation if the victim recovers from cardiac arrest&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The importance of recognizing the critical situation and&#47;or heart attack&#44; and of avoiding cardiac arrest&#44; as well as of the care following resuscitation&#44; is underscored by the inclusion of these elements in the four-link chain of survival&#46; The first link indicates the importance of recognizing individuals at risk of cardiac arrest&#44; and of calling for help in the hope that rapid patient care can avoid the arrest&#46; The central links of this chain in turn define the integration of CPR and defibrillation as the key components in early resuscitation&#44; in an attempt to restore life&#46; The end link&#44; advanced life support and effective treatment posterior to resuscitation&#44; focuses on the preservation of the vital signs of the patient &#8211; particularly referred to the heart and brain&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Description of the links in the chain of survival &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0040" class="elsevierStylePara elsevierViewall">As has been commented&#44; the first link in the chain is alerting the MES after recognizing the situation of cardiac arrest&#46; The number dialed is the same throughout Europe&#58; 112&#46; The alerting person must identify himself&#44; clearly explain what is happening to the patient&#44; identify the precise location&#44; and indicate whether CPR maneuvers will be started&#46; The indications of the dispatcher are to be followed&#44; and the latter must always be the last to hang up&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0045" class="elsevierStylePara elsevierViewall">The second link is basic CPR by the persons witnessing the arrest&#46; High-quality CPR can double or even triplicate survival&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0050" class="elsevierStylePara elsevierViewall">The third link in the chain is defibrillation&#44; which should take place as soon as possible&#46; In effect&#44; defibrillation is a key element in the chain of survival&#44; and is one of the few interventions to have been shown to improve the outcome of cardiac arrest with VF&#46; Since the effectiveness of the discharges quickly decreases with passing time&#44; defibrillation ideally should be carried out before the arrival of the MES &#8211; the average response time of the latter being no less than 8&#8211;10 min&#46; In this context&#44; AED are safe and effective when used by laypersons&#46; Thus&#44; ideally the first intervening person &#40;witness&#44; trained volunteer&#44; fireman&#44; policeman&#44; etc&#46;&#41; should be able to use an AED&#44; and the latter should be available in the first 3&#8211;5<span class="elsevierStyleHsp" style=""></span>min of arrest&#46; The new recommendations advocate the installation of AEDs in particularly busy public places&#44; and stress the importance of public access to defibrillation programs&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#46;</span><p id="par0055" class="elsevierStylePara elsevierViewall">The fourth and final link in the chain is represented by ALS and patient care after resuscitation&#46;</p></li></ul></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Prevention of arrest and early detection of the warning signs of potential sudden death</span><p id="par0060" class="elsevierStylePara elsevierViewall">Acute coronary syndrome &#40;ACS&#41; is the most common cause of cardiac sudden death&#46; Recognition of the cardiac origin of chest pain is very important&#44; since the probability of cardiac arrest secondary to acute myocardial ischemia is at least 21&#8211;33&#37; in the first hour after symptoms onset&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> The telephone call dialing 112 to activate the MES must be made as soon as the first symptoms are identified&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Recognizing cardiorespiratory arrest</span><p id="par0065" class="elsevierStylePara elsevierViewall">In many cases&#44; even for healthcare professionals&#44; it proves difficult to determine whether an unconscious person is in a state of cardiac arrest&#46; Healthcare professionals&#44; in the same way as laypersons performing resuscitation&#44; have difficulties determining the presence or absence of normal breathing in unresponsive victims&#44; since either the airway is not open&#44; or the patient is gasping&#46; In this context&#44; gasping is present in up to 40&#37; of all cases of cardiac arrest and in the first minutes&#44; and survival is favored when gasping is recognized as a sign of cardiac arrest&#46; Laypersons therefore should be instructed to start CPR if the victim is unconscious and fails to respond or does not breathe normally&#46; Adequate description of the condition of the patient is extremely important when calling the MES&#46; It is very important for the telephone operator or dispatcher to receive information on the breathing of the patient from the person who is calling&#46; Precision in the identification of cardiac arrest on the part of the telephone operators varies considerably&#46; If the operator adequately recognizes the situation&#44; appropriate measures can be taken&#44; such as CPR by witnesses under telephone guidance&#44; and the advanced life support units can ensure an adequate response&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Training of the dispatchers of out-hospital emergency services</span><p id="par0070" class="elsevierStylePara elsevierViewall">The telephone operators or dispatchers receiving the emergency calls must be trained through strict protocols in obtaining relevant information from the calling person&#46; This information is based on the recognition of the absence of response and on evaluation of the quality of breathing of the victim&#46; In the presence of a patient who fails to respond and does not breathe normally&#44; a suspected cardiorespiratory arrest &#40;CRA&#41; protocol should be activated immediately&#46; Gasping and short and noisy breathing on the part of the victim are not to be confused with normal breathing&#46; Gasping is present in 40&#37; of the cases in the first minutes of CRA&#44; and patient survival is improved when it is recognized as a sign of arrest&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Likewise&#44; the dispatchers must be trained to guide the calling person by telephone to perform CPR with chest compressions only&#46; Performing CPR only with compressions is better than performing no CPR maneuvers&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> When the calling person has no training in CPR&#44; the telephone operator should insist on the application of chest compressions until the MES arrives&#46; In the first minutes of CRA of cardiac origin&#44; the blood does not suffer important oxygen desaturation&#44; and compressions are a priority concern to ensure a minimum blood flow to the brain and myocardium&#44; with a view to maintaining sensitivity to defibrillation &#8211; increasing the chances for restored cardiac rhythm with an effective beat after defibrillation&#46; For every minute of delay in applying defibrillation&#44; survival following VF decreases 10&#8211;12&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a> It the person witnessing CRA performs CPR&#44; the decrease is only 3&#8211;4&#37;&#47;min&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#8211;10</span></a> Immediate CPR performed by witnesses on scene can double or even triple survival in cardiac arrest with VF&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">High-quality CPR</span><p id="par0075" class="elsevierStylePara elsevierViewall">The new recommendations underscore the importance of quality cardiac massage as a determinant factor for survival at hospital discharge among patients who have suffered cardiac arrest&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Cardiac massage</span><p id="par0080" class="elsevierStylePara elsevierViewall">Cardiac massage should be performed as follows&#58; the resuscitating person is to position himself alongside the victim and place the base of the palm of the hand on the center of the chest of the patient&#46; The base of the other hand is then placed parallel over that of the first&#44; intercrossing the fingers of both hands&#44; and compressing the chest of the patient with both arms extended and vertical &#8211; depressing the sternum at least 5<span class="elsevierStyleHsp" style=""></span>cm but no more than 6<span class="elsevierStyleHsp" style=""></span>cm&#46; The pressure is then relaxed completely to allow the chest of the patient to expand&#44; but without removing the hands from the chest&#46; The compression maneuvers are to be performed at a rate of between 100 and 120&#47;min&#46; The compressions and decompressions should have the same duration&#46; If the resuscitating person is able to do so&#44; two rescue breathings should be interspaced with a sequence of 30 compressions&#47;two ventilations&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">As a result of a lack of strength&#44; out of fear of causing injury&#44; and particularly due to fatigue&#44; some resuscitators compress the chest less deeply than indicated&#46; There is documented evidence that a minimum compression of 5<span class="elsevierStyleHsp" style=""></span>cm results in a greater rate of spontaneous circulatory recovery &#40;SCR&#41; than compression with a depth of 4<span class="elsevierStyleHsp" style=""></span>cm or less&#46; Damage produced by cardiac massage has not been shown to be directly related to the depth of chest compression&#44; and there are no studies indicating a limit to the depth of compression&#59; in any case&#44; however&#44; a depth of 6<span class="elsevierStyleHsp" style=""></span>cm should not be exceeded&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Rescue breathing</span><p id="par0090" class="elsevierStylePara elsevierViewall">In order to be effective&#44; rescue breathing should be carried out as follows&#58; the resuscitating person should open the patient airway by means of the forehead-chin maneuver&#44; clamping the nose with the thumb and index finger of the hand placed on the forehead and&#44; after a normal inspiration&#44; should insufflate air into the mouth of the patient&#44; using the lips to seal the mouth&#44; while confirming the rising chest of the victim&#46; The resuscitator then should draw back from the patient&#44; breathe in again&#44; and repeat the maneuver once the air has passively emerged from the chest of the patient&#46; Two respirations should be made in 5<span class="elsevierStyleHsp" style=""></span>s&#46; Immediately afterwards&#44; another sequence of 30 compressions should be started&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">CPR only with compressions</span><p id="par0095" class="elsevierStylePara elsevierViewall">Witnesses of a cardiac arrest who have had no training in CPR can perform cardiac massage alone&#44; following the real-time indications of a trained dispatcher&#46; In this case uninterrupted chest compressions are indicated at a rate of at least 100&#47;min&#44; but no more than 120&#47;min&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Lastly&#44; feedback for the resuscitating person is important to guarantee quality CPR&#46; During resuscitation&#44; devices can be used allowing immediate warning&#47;feedback&#46; The data recorded by the resuscitation equipment can also be used for resuscitation quality control&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Elimination of a predetermined period of CRP before defibrillation in out-hospital arrest not witnessed by the MES</span><p id="par0105" class="elsevierStylePara elsevierViewall">Different studies have demonstrated the beneficial impact of immediate CPR upon patient survival&#44; and the negative consequences of a delay in defibrillation&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;11&#44;13</span></a> Other studies have analyzed the convenience of applying a period of CPR before starting defibrillation in non-evidenced cardiac arrest&#44; or in those cases where some time has elapsed until the start of CPR&#46; Review of the evidence for the 2005 guides resulted in the recommendation for the MES to perform 2<span class="elsevierStyleHsp" style=""></span>min &#40;5 cycles of 30&#58;2&#41; of CPR before defibrillation in cases of prolonged arrest &#40;over 5<span class="elsevierStyleHsp" style=""></span>min&#41;&#46; The studies presented were carried out in arrests in which the time to response exceeded 4&#8211;5<span class="elsevierStyleHsp" style=""></span>min&#44; and in which the paramedics or physicians of the MES performed 1&#46;5&#8211;3<span class="elsevierStyleHsp" style=""></span>min of CPR before defibrillation&#46; This protocol improved SCR as well as survival at hospital discharge<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;15</span></a> and after 1 year in patients with out-hospital VF&#44; compared with the cases in which immediate defibrillation was carried out&#46; In two randomized&#44; controlled trials&#44; a period of 1&#46;5&#8211;3<span class="elsevierStyleHsp" style=""></span>min of CPR before defibrillation&#44; performed by the MES personnel&#44; did not improve either SCR or survival at discharge in VF&#44; independently of the response time of the MES&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;17</span></a> Other studies likewise have failed to demonstrate improvements in SCR or survival at discharge with initial CPR&#44;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a> although one reported a more favorable neurological prognosis 30 days and 1 year after arrest&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">There is scientific evidence that cardiac massage while placing the electrodes and loading the AED improves patient survival&#46; Therefore&#44; the MES team should perform CPR while the AED is being prepared&#44; the electrodes are placed on the patient&#44; and the device is being charged&#44; with a view to minimizing the interruption of chest compressions&#46; However&#44; the new recommendations do not specify a concrete duration of CRP &#40;2&#8211;3<span class="elsevierStyleHsp" style=""></span>min&#41; before analyzing cardiac rhythm and administering a discharge&#44; where indicated&#46; If some MES&#44; following the 2005 indications&#44; apply a certain duration of chest compressions before defibrillation&#44; they may continue with this practice&#44; in view of the lack of conclusive data indicating the need for changes in this sense&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Maintenance of cardiac massage while loading the AED</span><p id="par0115" class="elsevierStylePara elsevierViewall">Warranted by the scientific evidence&#44; the new recommendations underscore the importance of high-quality cardiac massage&#44; with the minimization of interruptions&#44; for improving patient survival&#46; Following these indications&#44; chest compression is to be continued while the AED is placed and used&#46; These defibrillators are safe and easy to use by laypersons&#44; and allow defibrillation of the patient before arrival of the MES&#46; Defibrillation technology advances quickly and now allows the evaluation of cardiac rhythm while CPR is performed&#44; and the resuscitating person can continue the chest compressions while the AED analyzes the rhythm and indicates the convenience or not of delivering a discharge&#46; In this way it is possible to minimize the time between interruption of the chest compressions and administration of the discharge &#40;pre-discharge pause&#41;&#46; A delay of only 5&#8211;10<span class="elsevierStyleHsp" style=""></span>s suffices to lessen the efficacy of defibrillation&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#8211;22</span></a> The pre-discharge pause can be reduced to less than 5<span class="elsevierStyleHsp" style=""></span>s if massaging is continued during loading of the AED&#44; and if the team is guided by an effective person&#46; Rigorous but rapid checking is required to ensure that nobody is in physical contact with the patient at the moment of the discharge&#46; The risk of someone on the resuscitating team receiving a discharge can be lessened if all members wear gloves during the intervention&#46; After defibrillation&#44; chest compression should be resumed immediately in order to reduce the post-discharge pause&#46; The entire process should be carried out without interrupting cardiac massage for more than 5<span class="elsevierStyleHsp" style=""></span>s&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Defibrillation is a key link in the chain of survival&#44; and one of the few interventions truly capable of improving survival in cardiac arrest due to VF&#46; The success of discharges decreases rapidly with passing time&#46; It is very difficult for defibrillation to be carried out by the MES in the first few minutes of arrest&#46; The intervention of trained volunteers has improved the outcome at hospital discharge&#44; and if defibrillation is carried out in the first 3<span class="elsevierStyleHsp" style=""></span>min of arrest&#44; the survival rate can reach 75&#37;&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">People trained in the use of the AED must be able to perform quality CPR until the MES arrives on scene&#46; The guides stress the importance of performing immediate CPR with high-quality compressions on an early and uninterrupted basis&#46; Compression should only be interrupted for as briefly as possible to perform ventilation&#44; analyze the cardiac rhythm or deliver a discharge&#44; and should be resumed immediately after defibrillation&#46; If two resuscitators are available&#44; one should prepare the AED&#44; position the electrodes on the naked chest of the patient and connect the defibrillator&#44; while the other should perform the chest compressions &#8211; interrupting them only to analyze the rhythm&#44; check that nobody is in contact with the patient&#44; and apply the discharge&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Sequence of BLS</span><p id="par0130" class="elsevierStylePara elsevierViewall">The sequence of maneuvers is described in <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Use of an AED</span><p id="par0135" class="elsevierStylePara elsevierViewall">AED are safe and effective&#44; even when used by laypersons&#44; and make it possible to apply defibrillation long before the arrival of professional help&#46; The resuscitators should continue CPR with minimum interruption of the chest compressions while the AED is being placed and during its use&#46; The resuscitators should follow the verbal instructions immediately&#44; and particularly must ensure the resumption of CPR&#46; The standard AED can be used with children over 8 years of age&#46; In the case of children between 1 and 8 years of age&#44; pediatric patches&#47;electrodes should be used&#44; together with an attenuator or pediatric operating mode&#44; if available&#46; If not available&#44; the AED should be used as is&#46; The use of these devices is not recommended in infants under 1 year of age&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Sequence of BLS and use of the AED</span><p id="par0140" class="elsevierStylePara elsevierViewall">The sequence of interventions is shown in <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Public access to defibrillation &#40;PAD&#41; programs</span><p id="par0145" class="elsevierStylePara elsevierViewall">Public access to defibrillation programs should be targeted to public places such as airports&#44; train or subway stations&#44; sports centers&#44; industrial centers&#44; commercial centers&#44; stadiums&#44; offices&#44; casinos and airplanes&#44; i&#46;e&#46;&#44; places where cardiac arrest can be witnesses and where trained resuscitators can quickly appear on scene&#46; PAD programs involving laypersons as resuscitators and with short response times&#44; using police personnel as first intervening persons&#44; have resulted in survival rates of between 49 and 74&#37;&#46; Accordingly&#44; PAD programs can only offer success if trained resuscitators and AEDs in sufficient number are available&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#44;21</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">However&#44; the great potential benefit of AEDs has not yet been materialized&#44; since these devices are generally located in public places&#44; and almost 80&#37; of all cardiac arrests occur in the home or in residential areas&#46; PAD programs and the use of AEDs by first intervening resuscitators can serve to increase the number of victims that receive CPR by witnesses&#44; and early defibrillation&#46; When developing such a program&#44; the community supervisors must assess factors such as adequate emplacement of the AED&#44; based on previous incidence or population concentration studies&#59; the training of a team in charge of monitoring and maintaining the devices&#59; the training of people who probably will use the AEDs&#59; and&#44; if possible&#44; identify those individual volunteers agreeing to use the device on the victims of cardiac arrest&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">The installation of AEDs in residential areas has not been studied to date&#44; and the acquisition of an AED for individual use in the home &#8211; even among individuals considered to be at high risk of cardiac arrest &#8211; has not been evaluated&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">In order for AED installation and the PAD program to offer maximum effectiveness&#44; the American Heart Association &#40;AHA&#41; has underscored the need to incorporate a series of elements<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a>&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">1&#46;</span><p id="par0165" class="elsevierStylePara elsevierViewall">Organization and planning of the response in the event of an emergency situation&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">2&#46;</span><p id="par0170" class="elsevierStylePara elsevierViewall">Training of the possible resuscitators both in handling of the AED and in applying CPR&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">3&#46;</span><p id="par0175" class="elsevierStylePara elsevierViewall">Connections to the local MES&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">4&#46;</span><p id="par0180" class="elsevierStylePara elsevierViewall">Establishment of a continued quality improvement process&#44; analyzing from adequate operation of the AEDs and the required electrodes to adequacy of the response system and competence of the resuscitators&#46;</p></li></ul></p><p id="par0185" class="elsevierStylePara elsevierViewall">It has been shown that places in which an AED has been located without all these elements are unlikely to improve survival among cardiac arrest patients&#44; since the mere presence of these devices does not mean that they will be used in the event of need&#44; or that they will be used correctly&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">ILCOR universal AED sign</span><p id="par0190" class="elsevierStylePara elsevierViewall">The ILCOR has unanimously approved the suggestion by its work group to adopt a universal sign indicating the presence of an AED&#46; The sign has been designed according to the ISO 7010 norm for safety signs and models&#46; The colors and symbols in turn comply with the ISO 3864-3 norm&#44; and its interpretability has been confirmed according to the ISO 9186-1&#44; rev&#46; 2007 norm&#44; proving to be superior to other designs&#46; The AED sign &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41; aims to indicate the presence of the device&#44; its location in any room or container&#44; for both public use and to indicate the direction in which to go in order to reach it&#46; The sign should serve to quickly identify an AED in a public place for immediate use on a cardiac arrest victim&#46; To this effect&#44; the AED can be combined with other symbols such as an arrow&#46; The sign can also be accompanied by the letters &#8220;AED&#8221;&#44; or the equivalent in other languages&#46; The full term &#8220;defibrillator&#8221; &#40;or equivalent&#41; is not recommended&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0195" class="elsevierStylePara elsevierViewall">It is the aim of the ILCOR to have this sign approved throughout the world by the respective national resuscitation councils&#46; The sign also must be approved by all AED manufacturers for use with their products&#44; and by the signaling industry&#46; The different public organizations and governments in turn should promote the universal adoption of this AED sign&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">In this sense&#44; it is to be expected that this universal sign will enhance awareness of the existence of these devices and will contribute to their rapid incorporation in emergency situations in the form of cardiac arrest &#40;<a href="https://www.erc.edu/index.php/newsItem/in/nid=204/">https&#58;&#47;&#47;www&#46;erc&#46;edu&#47;index&#46;php&#47;newsItem&#47;in&#47;nid&#61;204&#47;</a>&#41;&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Summary of changes since the guides of 2005</span><p id="par0205" class="elsevierStylePara elsevierViewall">Lastly&#44; it should be mentioned that many of the recommendations of the European Resuscitation Council &#40;ERC&#41; Guides 2005 remain without change &#8211; either because no new studies have been published&#44; or because the new evidence available since 2005 has simply reinforced the already existing evidence&#46; Nevertheless&#44; the evidence published since 2005 does point to the need to incorporate changes to some parts of the new Guide 2010&#46; In summarized form&#44; the changes of 2010&#44; in relation to the Guides 2005&#44; referred to BLS and AED are the following<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8226;</span><p id="par0210" class="elsevierStylePara elsevierViewall">Emergency telephone operators must be trained to question people who call&#44; using strict protocols for obtaining information&#46; This information should center on recognizing a lack of patient response and on the quality of breathing&#46; In combination with the absence of response&#44; the absence of breathing or any other breathing anomaly should serve to activate the telephone operator protocol for suspected cardiac arrest&#46; The importance of gasping as a sign of cardiac arrest is underscored&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8226;</span><p id="par0215" class="elsevierStylePara elsevierViewall">All resuscitators&#44; whether trained or otherwise&#44; should perform chest compressions on victims of cardiac arrest&#46; It remains essential to stress the importance of high-quality chest compression&#46; The aim should be to compress to a depth of at least 5<span class="elsevierStyleHsp" style=""></span>cm&#44; with a frequency of at least 100<span class="elsevierStyleHsp" style=""></span>compressions&#47;min&#44; allowing full chest rebound&#44; and minimizing interruptions of chest compression&#46; Trained resuscitators also should perform ventilations with a compression&#47;ventilation ratio of 30&#58;2&#46; In the case of non-trained resuscitators&#44; CPR only with chest compressions guided by telephone is advocated&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">&#8226;</span><p id="par0220" class="elsevierStylePara elsevierViewall">Devices allowing interactive messages during CPR will offer resuscitators immediate feedback&#44; and their use is thus encouraged&#46; The data stored by the resuscitation equipment can be used to supervise and improve the quality of CPR&#44; and supply information to the professional resuscitators during the revision sessions&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">&#8226;</span><p id="par0225" class="elsevierStylePara elsevierViewall">These guides underscore the importance of performing early chest compressions without interruptions&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">&#8226;</span><p id="par0230" class="elsevierStylePara elsevierViewall">Much greater emphasis is now placed on the need to minimize the duration of the pauses before and after AED discharge&#59; continuation of chest compression during loading of the device is recommended&#44; with immediate resumption of compression after defibrillation&#46; The defibrillator discharge should be completed with no more than a 5-s interruption of the chest compressions&#46;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">&#8226;</span><p id="par0235" class="elsevierStylePara elsevierViewall">The safety of the resuscitator remains essential&#44; although these guides recognize that the risk of damage with a defibrillator is very small &#8211; particularly when gloves are worn&#46; Attention now focuses on rapid safety checking&#44; in order to minimize the pre-discharge pause&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">&#8226;</span><p id="par0240" class="elsevierStylePara elsevierViewall">In the case of cardiac arrest outside the hospital&#44; the MES personnel should provide quality CPR&#46; With the availability of a defibrillator&#44; the device should be placed and loaded&#44; although it is no longer recommended to systematically perform prior CPR&#44; e&#46;g&#46;&#44; for a period of 2 or 3<span class="elsevierStyleHsp" style=""></span>min&#44; before the analysis of cardiac rhythm and discharge&#46; If some MES have fully incorporated certain duration of chest compressions before defibrillation to their intervention protocol&#44; they may reasonably continue with this practice&#44; in view of the lack of conclusive data indicating the need for changes in this sense&#46;</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">&#8226;</span><p id="par0245" class="elsevierStylePara elsevierViewall">Increased development of the PAD programs is encouraged&#44; underscoring the need for an increased distribution of AEDs in both public and residential areas&#46;</p></li></ul></p></span></span></span>"
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              "titulo" => "The chain of survival"
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              "titulo" => "Prevention of arrest and early detection of the warning signs of potential sudden death"
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              "titulo" => "Maintenance of cardiac massage while loading the AED"
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              "titulo" => "Sequence of BLS"
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            2 => "Basic life support"
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        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">During resuscitation&#44; basic life support &#40;BLS&#41; and automated external defibrillation refer to maneuvers designed to maintain airway patency and support breathing and circulation without equipment other than a barrier device and the use of an automated external defibrillator &#40;AED&#41;&#46; We present some of the most important developments incorporated into the new international recommendations for resuscitation 2010&#46; Aspects related to prevention and early detection of cardiac arrest are highlighted&#44; along with the important role of dispatchers of emergency medical services&#44; the importance of high quality CPR and programs of public access defibrillation&#46; We likewise describe sequences of action and basic life support algorithms&#44; and semi-automated external defibrillation&#46;</p>"
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        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Durante la resucitaci&#243;n&#44; el soporte vital b&#225;sico &#40;SVB&#41; y la desfibrilaci&#243;n externa autom&#225;tica hacen referencia a las maniobras de mantenimiento de la permeabilidad de la v&#237;a a&#233;rea&#44; el apoyo de la respiraci&#243;n y de la circulaci&#243;n&#44; sin el uso de otro equipo que un dispositivo de barrera&#44; y el uso de un desfibrilador externo autom&#225;tico &#40;DEA&#41;&#46; Se presentan a continuaci&#243;n algunas de las novedades m&#225;s importantes que incorporan las nuevas recomendaciones internacionales en resucitaci&#243;n de 2010&#46; Se destacan los aspectos relacionados con la prevenci&#243;n y detecci&#243;n precoz de la parada cardiaca&#44; el papel importante de los teleoperadores de los servicios de emergencias m&#233;dicas&#44; la importancia de la resucitaci&#243;n cardiopulmonar de alta calidad y de los programas de acceso p&#250;blico a la desfibrilaci&#243;n&#46; Se presentan las secuencias de actuaci&#243;n y algoritmos de soporte vital b&#225;sico y desfibrilaci&#243;n externa semiautom&#225;tica&#46;</p>"
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