BLS Resuscitation Notes

The principles of basic life support (BLS) were introduced in 1960. Since then, specific techniques for the management of cardiac arrest and the delivery of emergency and cardiac care have been reviewed and revised every 5 to 6 years. The goal is to produce the best recommendations possible given the available scientific evidence. Elements of BLS - - Basic life support (BLS) is noninvasive emergency lifesaving care that is used to treat medical conditions, including airway obstruction, respiratory arrest, and cardiac arrest. Care focuses on the ABCs: - Airway (obstruction) - Breathing (respiratory arrest) - Circulation (cardiac arrest or severe bleeding) If the patient is in cardiac arrest, a CAB sequence (compressions, airway, breathing) is used. - Chest compressions are essential and must be started as quickly as possible. Cardiopulmonary Resuscitation (CPR) The steps for cardiopulmonary resuscitation (CPR) include: 1. Restore circulation by performing chest compressions to circulate blood to the vital organs of the body. 2. Perform 30 high-quality compressions to a depth of 2 to 2.4 inches (5 󳆫to 6 cm) in an adult at the rate of 100 to 120 per minute. 3. Open the airway with the jaw-thrust or head tilt–chin lift maneuver. 4. Restore breathing by providing rescue breaths (via mouth-to-mask ventilation or a bag-valve mask [BVM]). 5. Administer 2 breaths, each over 1 second, while visualizing for chest rise. Advanced life support (ALS) involves advanced lifesaving procedures, such as cardiac monitoring, administration of intravenous (IV) fluids and medications, and the use of advanced airway adjuncts. When done correctly, BLS care can maintain life for a short time until ALS measures can be started. To survive cardiac arrest, effective CPR at an adequate rate and depth with minimal interruptions is essential until defibrillation can be administered. The Components of CPR The American Heart Association (AHA) has determined the chain of survival that can improve the chance of successful resuscitation of a patient who experiences sudden cardiac arrest. A successful resuscitation is defined not only by the return of spontaneous circulation = the return of pulse and effective blood flow to the body in a patient who before was in cardiac arrest (ROSC), but also the survival of the patient to hospital discharge. The five links in the chain of survival are: 1. Recognition and activation of the emergency response system: a. The first step in the chain of survival requires public education and awareness. b. Laypeople must learn to recognize the early warning signs of a cardiac emergency and immediately activate EMS by calling 9-1-1. i. This ensures that emergency responders are dispatched 󳆫to the scene quickly, allowing the other links of the chain to be more effective. c. In modern EMS systems, the 9-1-1 dispatcher can provide pre arrival instructions and direct the caller to provide CPR if needed. 2. Immediate, high-quality CPR: a. The initiation of immediate CPR by a bystander is essential for successful resuscitation of a person in cardiac arrest. b. The more people trained in CPR in the community, the better the chances of CPR being administered quickly to a person in cardiac arrest. c. Because a perception that bystander CPR involves both mouth-to-mouth breathing and chest compressions persists, laypeople should be educated in performing compression-only (hands-only) CPR. d. Chest compressions must be given hard and fast. e. Compressions should be between 2 and 2.4 inches in depth (5 to 6 cm) and given at a rate of 100 to 120 per minute. f. The chest should completely recoil between each compression to maximize blood return to the heart. g. Never lean on the chest between compressions. h. Minimize interruptions between compressions. 3. Rapid defibrillation: a. Provided that immediate, high-quality CPR with minimal interruption is performed, early defibrillation offers the best opportunity to achieve a successful patient outcome. b. Automated external defibrillators (AEDs) are readily available in many public venues. c. The simple design of the AED makes it easy for emergency medical providers and laypeople to use with very little training. 4. Basic and advanced emergency medical services: a. Care includes: i. Continuing high-quality CPR ii. Basic airway management (ie, oral airway insertion, BVM ventilation) iii. Advanced airway management (ie, endotracheal [ET] intubation or use of supraglottic airway devices) iv. Manual defibrillation v. Vascular access vi. Transcutaneous pacing vii. Administration of medications b. Be familiar with the cardiac resuscitation centers in your service area. 5. Advanced life support and post arrest care: a. Further cardiopulmonary and neurologic support can include: i. Additional medication therapy to support blood pressure ii. Targeted temperature management (ie, therapeutic hypothermia) iii. Maintenance of blood glucose levels iv. Cardiac catheterization v. An electroencephalogram to detect seizure activity vi. Admission to the intensive care unit for critical care management Assessing the Need for BLS Survey the scene: - Is the scene safe? - How many patients are present? - What is your initial impression of the patient(s)? - Are bystanders present who may have additional information? - What is the mechanism of injury or nature of illness? - Do you suspect trauma? - Does the dispatch information match what you see? Primary assessment involves: - Determining unresponsiveness - Gently tap the patient on the shoulder and shout, “Are you okay?” - A person who is unresponsive may or may not need CPR. - Simultaneously checking for breathing and a pulse This should take no more than 10 seconds. If the patient is in cardiac arrest, begin CPR immediately. Basic Principles of BLS For the purposes of BLS: - Anyone younger than 1 year of age is considered an infant. - A child is between 1 year of age and the onset of puberty (approximately 12 to 14 years of age), as signified by breast development in girls and underarm, chest, and facial hair in boys. - Adulthood is from the onset of puberty and older. - Some small children may best be treated as infants, some larger children as adults. There are two basic differences in providing CPR for infants, children, and adults. - The emergencies in which infants and children require CPR usually have different underlying causes. - There are anatomic differences in adults, children, and infants, such as smaller airways in infants and children than in adults. In most cases, cardiac arrest in children results from respiratory arrest. If untreated, respiratory arrest will quickly lead to cardiac arrest and death. Automated External Defibrillation Most prehospital cardiac arrests occur as the result of a sudden cardiac rhythm disturbance (dysrhythmia), such as: - Ventricular fibrillation (V-fib) - The disorganized quivering of the ventricles, resulting in no forward blood flow and a state of cardiac arrest - Pulseless ventricular tachycardia (V-tach) - A rapid contraction of the ventricles that does not allow for normal filling of the heart Early defibrillation improves survival rates. AEDs can safely be used in children using the pediatric-sized pads and a dose-attenuating system (energy reducer). - If these items are unavailable, use adult-size AED pads. Apply the AED to infants or children after the first five cycles of CPR have been completed. Cardiac arrest in children is usually the result of respiratory failure; therefore, oxygenation and ventilation are vitally important. If the patient is an infant (between 1 month and 1 year of age), a manual defibrillator is preferred to an AED. Call for ALS backup immediately. - If ALS backup with a manual defibrillator is unavailable, an AED equipped with pediatric-sized pads and a dose attenuator is preferred. - If neither is available, then use an AED with adult-sized pads. - If you use adult-size AED pads on an infant or small child, do not cut the pads to adjust the size. - Instead, use the anterior-posterior placement, following the manufacturer’s recommendation. Considerations When Using an AED Pacemakers and implanted defibrillators: - Used in patients who are at a high risk for certain cardiac dysrhythmias and cardiac arrest - AICDs, or pacemakers, create a hard lump beneath the skin, usually on the upper left side of the chest (just below the clavicle). - - If the AED pads are placed directly over the device, then the effectiveness of the shock delivered may be reduced, and the shock could potentially damage the implanted device. Place the AED pads at least 1 inch (2.5 cm) away from the device. If you observe the patient’s muscles twitching as if he or she was just shocked, continue CPR and wait 30 to 60 seconds before delivering a shock from the AED. Wet patients: - The AED should not be used in water because water conducts electricity. - If the patient’s chest is wet, the electrical current may move across the skin rather than between the pads to the patient’s heart. - If the patient is submerged in water, pull him or her out of the water and quickly dry the skin before attaching the AED pads. - Do not delay CPR to dry the patient thoroughly; instead, quickly wipe off as much moisture as possible from the chest. - If the patient is lying in a small puddle of water or in the snow, the AED can be used, but the patient’s chest should be quickly dried as much as possible. Transdermal medical patches: - Transdermal patches allow medication to be absorbed through the skin. - The patch could reduce the flow of the electrical current from the AED to the heart and may burn the skin. - If the medication patch interferes with AED pad placement, remove the patch with your gloved hands and wipe the skin to remove any residue prior to attaching the AED pad. Positioning the Patient - - If the patient is crumpled up or lying face down (prone), move him or her to a supine position. You cannot rule out a spinal injury in an unresponsive patient, so protect the patient’s neck and move him or her as a unit, without twisting. If the patient is found in a bed, then move him or her to the floor. Log roll the patient onto a long backboard as you position him or her for CPR as quickly and safely as possible. - A backboard will provide support during transport and emergency care. After the patient is properly positioned, assess to determine whether CPR and defibrillation are necessary. . Cardiac arrest in children is usually the result of respiratory failure, whereas a sudden cardiac rhythm disturbance is the primary cause of cardiac arrest in adults. Check for Breathing and Pulse Visualize the chest for signs of breathing while palpating for a carotid pulse. Feel for the carotid artery by locating the larynx at the front of the neck and then sliding two fingers toward one side (the side closest to you). - The pulse is felt in the groove between the larynx and sternocleidomastoid muscle, with the pads of the index and middle fingers held side by side. Light pressure is sufficient to palpate the pulse. Provide External Chest Compressions - - Chest compressions are administered by applying rhythmic pressure and relaxation to the lower half of the sternum. - Compressions squeeze the heart, acting as a pump to circulate blood. Allow the chest to completely recoil between compressions, which enhances blood return to the heart. Do not lean on the chest between compressions. When artificial ventilation is provided, the blood that is circulated through the lungs during chest compressions is likely to receive adequate oxygen to maintain tissue perfusion. - Even when external chest compressions are performed properly, they circulate only one-third of the blood that is normally pumped by the heart. Complications Complications from chest compressions can include: - Fractured ribs - Lacerated liver - Fractured sternum Your motions must be smooth, rhythmic, and uninterrupted. - Short, jabbing compressions are not effective in producing artificial blood flow. Do not remove the heel of your hand from the patient’s chest during relaxation, but make sure that you completely release pressure on the sternum so that it can return to its normal resting position between compressions. Opening the Airway and Providing Artificial Ventilation The head tilt–chin lift maneuver is effective for opening the airway in most patients when there is no indication of a spinal injury. - If the patient has any foreign material or vomitus in the mouth, quickly remove it. - Remove any liquid materials from the mouth with a suction device. - Use your hooked index finger to remove any solid material. If spinal injury is suspected, use the jaw-thrust maneuver. - Do not tilt the patient’s head back, because you want to minimize movement of the patient’s neck. - Place your fingers behind the angles of the patient’s lower jaw and then move the jaw upward. - Keep the head in a neutral position as you move the jaw upward and open the mouth. - If the patient’s mouth remains closed, use your thumbs to pull down the patient’s lower lip to allow breathing. If the jaw thrust fails to open the airway, use the head tilt–chin lift. Recovery Position - - - - The recovery position helps to maintain a clear airway in a patient with a decreased level of consciousness who has not sustained traumatic injuries and is breathing adequately on his or her own. - It also allows vomitus to drain from the mouth. Roll the patient onto his or her side so that the head, shoulders, and torso move as a unit, without twisting. Place the top hand under his or her cheek. Never place a patient who has a suspected head or spinal injury in the recovery position because: - The spine is not aligned - Spinal stabilization is not possible - Further spinal injury could result If the patient has a hip or pelvic injury, positioning the patient on his or her side could cause fractured bone ends to compress or sever large arteries and veins, resulting in severe internal bleeding. Suspect an associated spinal injury in any unresponsive patient with a hip or pelvic injury until proven otherwise. Provide Artificial Ventilations - Ventilations can be given by one or two EMS providers. Use a barrier device, such as a pocket mask with a one-way valve, or a BVM. Give supplemental oxygen when possible. Devices with an oxygen reservoir provide higher percentages of oxygen to the patient. Observe the chest for visible rise to assess the effectiveness of your ventilations. Hyperventilation (rapid or deep breathing that lowers blood carbon dioxide level below Normal) may cause increased intrathoracic pressure. - This reduces the amount of blood that returns to the heart, decreasing the effectiveness of chest compressions and resulting in the heart and brain receiving decreased amounts of oxygen. Stoma Ventilation - A stoma is an opening that connects the trachea directly to the skin. Patients with a stoma should be ventilated with a BVM or pocket mask device placed directly over the stoma. If air leakage through the nose and mouth interferes with ventilation through the stoma, cover the nose and mouth with your hand to make a seal. Use a pediatric or infant mask to ventilate through the stoma. Gastric distension - - - Gastric distention (air fills stomach) occurs more easily in children, but also happens frequently in adults. Gastric distention is likely to occur if you hyperventilate the patient, so it is important for you to give slow, gentle breaths. - Such breaths are more effective in ventilating the lungs. Excessive inflation of the stomach is dangerous because: - It can cause the patient to vomit during CPR. - It can reduce lung volume by elevating the diaphragm. If massive gastric distention interferes with adequate ventilation, contact medical control. Check the airway again. Reposition the patient. Watch for rise and fall of the chest. Have a suction unit available in case the patient vomits. Switching Positions - - The switch between the two rescuers can be accomplished by doing the following: - Rescuer one (the first compressor) should finish the cycle of 30 compressions while the second rescuer moves to the opposite side of the chest and moves into position to begin compressions. - Rescuer one should deliver two rescue breaths and then rescuer two should take over compressions by administering 30 chest compressions. - Rescuer one will then deliver two ventilations and the CPR cycles will continue as needed until the next 2-minute mark (five cycles) is reached, at which time the process will be repeated. If there are only two rescuers on scene, the two rescuers will alternate positions. If additional rescuers are available, the compressor should rotate every 2 minutes. - During switches, minimize the time that no compressions are being administered. It should take less than 5 seconds to switch compressors. Devices and Techniques to Assist Circulation Although improved patient outcomes have not yet been documented, mechanical devices may be considered for use as an adjunct to CPR in select settings when used by properly trained personnel for patients in cardiac arrest in the prehospital or in-hospital setting. Specific settings include instances when: - Limited rescuers are available - CPR is prolonged - CPR is required in a moving ambulance Mechanical devices include: Active compression-decompression CPR: - Active compression-decompression CPR is a technique that involves compressing the chest and then actively pulling it back up to its neutral position or beyond (decompression). - This technique may increase the amount of blood that returns to the heart and the amount of blood ejected from the heart during compression-decompression CPR. - The device features a suction cup that is placed in the center of the chest. - After compressing the chest to the proper depth, the rescuer pulls up on the handle of the device to provide active decompression of the chest, ensuring that the chest returns to at least its neutral position, or even beyond neutral. Impedance threshold device (ITD) - An impedance threshold device (ITD) is a valve device placed between the ET tube and a BVM. - May also be placed between the bag and mask if an ET tube is not in place. - The ITD is designed to limit the air entering the lungs during the recoil phase between chest compressions. - Results in negative intrathoracic pressure that may draw more blood toward the heart, ultimately resulting in improved cardiac filling and circulation during each chest compression - The ITD may be considered when used together with devices that provide active compression-decompression CPR. - It is not currently recommended for use with conventional CPR. - If ROSC occurs, remove the ITD. Mechanical piston device - A mechanical piston device is a device that depresses the sternum via a compressed gas–powered or electric-powered plunger mounted on a backboard. - - - The patient is positioned supine on the backboard, with the piston positioned on top of the patient with the plunger centered over the patient’s thorax in the same manner as with manual chest compressions. The device is then secured to the backboard. This device allows rescuers to configure the depth and rate of compressions, resulting in consistent delivery. - This frees the rescuer to complete other tasks and eliminates rescuer fatigue that results from continuous delivery of manual chest compressions. These devices have been available for many years. - The latest versions offer you the option of providing compressions using a battery instead of an oxygen tank or a compressed air system, thus eliminating the tanks and hoses. Load-distributing band (LDB) - A load-distributing band (LDB) is a circumferential chest compression device composed of a constricting band and backboard - The device is either electrically or pneumatically driven to compress the heart by putting inward pressure on the thorax. - Use of the LDB frees the rescuer to complete other tasks. - The device weighs less than the early-version mechanical piston devices and can be easier to apply. Infant and Child CPR Cardiac arrest in infants and children follows respiratory arrest, which triggers hypoxia and ischemia (lack of oxygen that deprives tissues of nutrients resulting from partial or complete blockage of blood flow) of the heart. Respiratory issues leading to cardiopulmonary arrest in children can have a number of causes, including: - Injury, both blunt and penetrating - Infections of the respiratory tract or another organ system (croup, epiglottitis) - A foreign body in the airway - Submersion (drowning) - Electrocution - Poisoning or drug overdose - Sudden infant death syndrome (SIDS) Determining Responsiveness - Never shake a child to determine whether he or she is responsive, especially if there is a possibility of a neck or back injury. - - Instead, gently tap the child on the shoulder, and say loudly, “Are you okay?” - With an infant, gently tap the soles of the feet. If a child is responsive but struggling to breathe, allow him or her to remain in whatever position is most comfortable. If the child is unresponsive, apneic, and pulseless and you did not witness the child’s collapse, perform CPR beginning with chest compressions for approximately five cycles (about 2 minutes), and then stop to call 9-1-1 and retrieve an AED. - Do not call 9-1-1 right away, as you would with an adult. - Children require immediate restoration of oxygenation, ventilation, and circulation, which can be accomplished by immediately performing five cycles of CPR before activating the EMS system. Check for Breathing and a Pulse - - - Visualize the chest for signs of breathing and palpate for a pulse in a large central artery. - You can usually palpate the carotid or femoral pulse in children older than 1 year, but it is difficult in infants. - In infants, palpate the brachial artery, located on the inner side of the arm, midway between the elbow and shoulder. - Place your thumb on the outer surface of the arm between the elbow and shoulder. - Place the tips of your index and middle fingers on the inside of the biceps, and press lightly toward the bone. CPR is required if the infant or child is not breathing or is not breathing normally (agonal gasps), and a pulse is absent (or less than 60 beats/min). As with an adult, an infant or child must be lying on a hard, flat surface for effective chest compressions. If you need to carry an infant while providing CPR, use your forearm and hand as the flat surface. - Use your palm to support the infant’s head. - The infant’s shoulders are elevated, and the head is slightly tilted back in a position that will keep the airway open. - Ensure that the infant’s head is not higher than the rest of the body. Anatomical differences in children and infants include: - The liver (immediately under the right side of the diaphragm) is relatively large and fragile, especially in infants. - The spleen is smaller and more fragile in children than in adults. - The chest of an infant is smaller and more pliable than that of an older child or adult. - You should use only two fingers to compress the chest - If two rescuers are performing CPR on an infant, use the two-thumb-encircling-hands technique to deliver chest compressions. - In children, especially those older than 8 years, you can use the heel of one or both hands to compress the chest. Airway - - - If a child is unresponsive and lying in a supine position, the airway may become obstructed when the tongue and throat muscles relax and the tongue falls backward. If the child is unresponsive but breathing adequately, place him or her in the recovery position to maintain an open airway and allow drainage of saliva, vomitus, or other secretions from the mouth. - Do not use this position if you suspect injury to the spine, hips, or pelvis unless you can secure the child to a backboard that can be tilted to the side. If the child is responsive and breathing, but in a labored fashion, provide prompt transport to the closest appropriate hospital. Because a child’s neck is flexible, the jaw-thrust maneuver is the best method to use if you suspect a spinal injury in a child. - A second rescuer should immobilize the child’s cervical spine. If spinal injury is not suspected, modify the head tilt–chin lift maneuver so that, as you tilt the head back, you are moving it only into the neutral position or a slightly extended position. Performing the Head Tilt–Chin Lift and Jaw-Thrust Maneuvers on a Child When dealing with a child, you will need to modify the: Head tilt–chin lift maneuver - Perform the head tilt–chin lift maneuver in a child in the following manner: - Place one hand on the child’s forehead and tilt the head back gently, with the neck slightly extended. - Place two or three fingers (not the thumb) of your other hand under the child’s chin and lift the jaw upward and outward. Do not close the mouth or push under the chin; either move may obstruct rather than open the airway. - Remove any visible foreign body or vomitus Jaw-thrust maneuver - Perform the jaw-thrust maneuver in a child in the following manner: - Place two or three fingers under each side of the angle of the lower jaw; lift the jaw upward and outward. - If the jaw thrust alone does not open the airway and cervical spine injury is not a consideration, tilt the head slightly. - If cervical spine injury is suspected, use a second rescuer to immobilize the cervical spine Provide Rescue Breathing - - If the child is not breathing but has a pulse, open the airway and deliver one breath every 3 to 5 seconds (12 to 20 breaths/min). If the child is not breathing and does not have a pulse, deliver 2 rescue breaths after every 30 chest compressions (15 chest compressions if 2 rescuers are present). - Each ventilation should last about 1 second and should produce visible chest rise. Use the proper-sized mask and ensure an adequate mask-to-face seal. If an infant or small child is breathing, provide prompt transport. Allow a child in respiratory distress to stay in whatever position is most comfortable. Keep children who are unresponsive but breathing with difficulty in a position that allows you to manage the airway and provide ventilatory support. In a child with a tracheostomy tube in the neck, remove the mask from the BVM and connect it directly to the tracheostomy tube to ventilate the child. - If a BVM is unavailable, a face mask with a one-way valve or other barrier device over the tracheostomy site can be used. - Place your hand firmly over the child’s mouth and nose to prevent the artificial breaths from leaking out of the upper airway. Interrupting CPR - - Chest compression fraction is the total percentage of time during a resuscitation attempt in which chest compressions are being performed. Make every effort to maintain a chest compression fraction of at least 60% (the higher the better). The more frequent the interruptions in chest compressions, the lower the compression fraction will be. - Low compression fractions lead to worse patient outcomes. Most modern cardiac monitors provide information about chest compression fraction that you can review after a cardiac arrest. - Routinely review this information after every arrest so that you can learn ways to improve the chest compression fraction and other key performance indicators. When Not to Start CPR There are only three general exceptions to starting CPR on a patient: 1. Do not start CPR if the scene is unsafe. 2. Do not start CPR if the patient has obvious signs of death, including an absence of a pulse and breathing, along with: - Rigor mortis, or stiffening of the body after death - Dependent lividity (livor mortis), a discoloration of the skin caused by pooling of blood - Putrefaction (decomposition of the body tissues) - Evidence of non survivable injury, such as decapitation, dismemberment, or being burned beyond recognition - Rigor mortis and dependent lividity develop after a patient has been dead for a long period. 3. Do not start CPR if the patient and his or her physician have previously agreed on a do not resuscitate (DNR) order or no-CPR order. - DNR orders give you permission not to attempt resuscitation. - This may apply only to situations in which the patient is known to be in the terminal stage of an incurable disease. In this situation, CPR would only prolong the patient’s death. Directives - The safest course is to begin CPR under the rule of implied consent and then contact medical control for further guidance. If a valid DNR document or living will is produced, resuscitative efforts may be withheld. Physician Orders for Life-Sustaining Treatment (POLST) and Medical Orders for Life-Sustaining Treatment (MOLST) are legal documents that describe acceptable interventions for the patient in the form of medical orders and must be signed by an authorized medical provider to be valid. - If you are presented with a POLST or MOLST form, then contact medical control for guidance. When to Stop CPR After you begin CPR in the field, you must continue until one of the following events occurs (the STOP mnemonic): - S: The patient Starts breathing and has a pulse. - T: The patient’s care is Transferred to another provider of equal or higher-level training. - O: You are Out of strength or too tired to continue CPR. - Out of strength does not mean merely weary; rather, it means that you are no longer physically able to perform CPR. - P: A Physician who is present or providing online medical direction assumes responsibility for the patient and directs you to discontinue CPR. Foreign Body Airway Obstruction in Adults An airway obstruction may be caused by: - Relaxation of the throat muscles in an unresponsive patient - Vomited or regurgitated stomach contents - Blood - Damaged tissue after an injury - Dentures - Foreign bodies such as food or small objects Large objects that are visible but cannot be removed from the airway with suction should be swept forward and out with your gloved index finger. - Suctioning can then be used as needed to keep the airway clear of thinner secretions such as blood, vomitus, and mucus. Management is based on the severity of the airway obstruction: Mild airway obstruction: - Patients with a mild (partial) airway obstruction are able to exchange adequate amounts of air, but still have signs of respiratory distress. - Breathing may be noisy. - The patient usually has a strong, effective cough. - Leave these patients alone! - Your main concern is to prevent a mild airway obstruction from becoming a severe (complete) airway obstruction. - Abdominal thrusts are not indicated for patients with a mild airway obstruction. - Encourage the patient to cough or to continue coughing if they are already doing so. - Do not interfere with the patient’s own attempts to expel the foreign body. - Give supplemental oxygen if needed and provide prompt transport to the ED. - Closely monitor the patient and observe for signs of a severe airway obstruction (weak or absent cough, decreasing level of consciousness, cyanosis). Responsive patients: - A sudden, severe airway obstruction is usually easy to recognize in someone who is eating or has just finished eating. - The person is suddenly unable to speak or cough, grasps his or her throat, turns cyanotic, and makes exaggerated efforts to breathe. - At first, the patient will be responsive and able to clearly indicate the problem. - Ask the patient, “Are you choking?” - If there is a minimal amount of air movement, you may hear a stridor. Unresponsive patients: - When you discover an unresponsive patient, your first step is to determine whether he or she is breathing and has a pulse. - If the patient has a pulse, but is not breathing, make sure that the airway is open and unobstructed. - Suspect an airway obstruction if the standard maneuvers to open the airway and ventilate the lungs are ineffective. - If you feel resistance when attempting to ventilate, the patient probably has some type of obstruction. Abdominal-Thrust Maneuver The manual maneuver recommended for removing severe airway obstructions in responsive adults and children older than 1 year is the abdominal-thrust maneuver (also called the Heimlich maneuver). 1. Stand behind the patient and wrap your arms around his or her abdomen. Straddle your legs outside the patient’s legs. This will allow you to easily slide the patient 󳆫to the ground if he or she becomes unresponsive. 2. Make a fist with one hand; grasp the fist with the other hand. Place the thumb side of the fist against the patient’s abdomen just above the umbilicus and well below the xiphoid process. 3. Press your fist into the patient’s abdomen with a quick inward and upward thrust. 4. Continue abdominal thrusts until the object is expelled from the airway or the patient becomes unresponsive. In responsive patients with a severe airway obstruction, repeat abdominal thrusts until the foreign body is expelled or the patient becomes unresponsive. Each thrust should be deliberate, with the intent of relieving the obstruction. If the patient with a severe airway obstruction is unresponsive, perform chest compressions. Chest Thrust For women in advanced stages of pregnancy and obese patients, use chest thrusts instead. 1. Stand behind the patient with your arms directly under the patient’s armpits, and wrap your arms around the patient’s chest. 2. Make a fist with one hand; grasp the fist with the other hand. Place the thumb side of the fist against the patient’s sternum, avoiding the xiphoid process and the edges of the rib cage. 3. Press your fist into the patient’s chest with backward thrusts until the object is expelled or the patient becomes unresponsive. If the patient becomes unresponsive, begin CPR, starting with chest compressions. Managing Airway Obstruction Use the following steps to manage the patient’s airway obstruction: 1. Carefully support the patient to the ground and immediately call for help (or send someone to call for help). 2. Perform 30 chest compressions, using󳆫 the same landmark as you would for CPR (center of the chest, between the nipples). Do not check for a pulse before performing chest compressions. 3. Open the airway and look in the mouth. If you see an object that can easily be removed, then remove it with your fingers and attempt to ventilate. If you do not see an object, then resume chest compressions. 4. Repeat steps 2 and 3 until the obstruction is relieved or ALS providers take over. If you are able to remove an object from the mouth, attempt to ventilate. - If ventilation produces chest rise, continue to ventilate and check for a pulse. - If a pulse is present but the patient is not breathing, continue rescue breathing and monitor the pulse. - If a pulse is absent, continue CPR (compressions and ventilations) and apply the AED as soon as it is available. When a patient is found unresponsive, begin CPR by determining unresponsiveness and checking for breathing and a pulse. - If a pulse is present but breathing is absent, open the airway and attempt to ventilate. - If the first ventilation does not produce visible chest rise, reposition the airway and reattempt to ventilate. - If both ventilation attempts do not produce visible chest rise, perform 30 chest compressions, and then open the airway and look in the mouth. If an object is visible and can easily be removed, remove it with your fingers and attempt to ventilate. Continue the sequence until the airway is clear or ALS providers arrive. Foreign Body Airway Obstruction in Infants and Children - - - Try to identify the cause of the obstruction as soon as possible. In patients who have signs and symptoms of an airway infection, do not waste time trying to dislodge a foreign body. - Administer supplemental oxygen if needed and immediately transport the child to the ED. As in adults, foreign bodies may cause a mild or a severe airway obstruction. - With a mild airway obstruction, the child can cough forcefully, although he or she may wheeze between coughs. As long as the patient can breathe, cough, or talk, do not interfere with his or her attempts to expel the foreign body. Encourage the child to continue coughing. Administer supplemental oxygen if needed (and tolerated) and provide transport to the ED. Intervene only if signs of a severe airway obstruction develop, such as: - A weak, ineffective cough - Cyanosis - Stridor Absent air movement A decreasing level of consciousness Removing a Foreign Body Airway Obstruction in a Child To perform the abdominal-thrust maneuver in a responsive child who is in a standing or sitting position, follow these steps: 1. Kneel on one knee behind the child, and circle both of your arms around the child’s body. Prepare to give abdominal thrusts by placing your fist just above the patient’s umbilicus and well below the xiphoid process. Place your other hand over that fist. 2. Give the child abdominal thrusts in an upward direction. Avoid applying force to the lower rib cage or sternum. 3. Repeat until the child expels the foreign body or becomes unresponsive. 4. If the child becomes unresponsive, position the child on a hard surface and immediately call for help (or send someone to call for help). 5. Perform 30 chest compressions (15 compressions if 2 rescuers are present), using the same landmark as you would for CPR. Do not check for a pulse before performing chest compressions. 6. Open the airway and look inside the mouth. If you see an object that can easily be removed, then remove it with your fingers and attempt to ventilate. If you do not see an object, then resume chest compressions. 7. Repeat steps 5 and 6 until the obstruction is relieved or ALS providers take over. If you manage to clear the airway obstruction in an unresponsive child but he or she still has no spontaneous breathing or circulation, perform CPR (compressions and ventilations) and apply the AED as soon as it is available. Removing a Foreign Body Airway Obstruction in Infants Follow these steps to remove a foreign body airway obstruction in an infant. 1. Hold the infant facedown, with the body resting on your forearm. Support the infant’s jaw and face with your hand, and keep the head lower than the rest of the body. 2. Deliver five back slaps between the shoulder blades, using the heel of your hand. 3. Place your free hand behind the infant’s head and back, and turn the infant face up on your other forearm and thigh, sandwiching the infant’s body between your two hands and arms. The infant’s head should remain below the level of the body. 4. Give five quick chest thrusts in the same location and manner as chest compressions, using two fingers placed on the lower half of the sternum. For larger infants, or if you have small hands, you can perform this step by placing the infant in your lap and turning the infant’s whole body as a unit between back slaps and chest thrusts. 5. Check the airway. If you can see the foreign body, then remove it. If not, then repeat the cycle as often as necessary. If the infant becomes unresponsive, begin CPR and follow the same sequence as for a child and adult. Do not check for a pulse before starting compressions. If you see an object that can easily be removed, remove it with your finger and attempt to ventilate. If you do not see an object, resume chest compressions. Continue the sequence until the obstruction is relieved or ALS providers take over. Special Resuscitation Circumstances Opioid overdose: - An opioid depresses the central nervous system and causes respiratory arrest followed by cardiac arrest. - Examples of opioids include heroin and oxycodone. - Naloxone blocks opiate receptors in the body and reverses the effect of opioid overdose. - If you respond to a patient who you suspect has overdosed on an opioid, and naloxone was administered by a bystander prior to your arrival, determine how much of the medication was given and the route by which it was given. - Your EMS medical director may implement a protocol that allows BLS providers to administer naloxone in cases of suspected opioid overdose. - Standard resuscitative measures take priority over naloxone administration. - Do not delay other interventions while waiting for the patient to respond to naloxone therapy. - Many patients who have overdosed on an opioid have a pulse (although slow) but are not breathing. - BVM ventilation is the most critical treatment, followed by administration of naloxone if it is available. Cardiac arrest in pregnancy: - If you encounter a pregnant patient who is in cardiac arrest, your priorities are to provide high-quality CPR and relieve pressure off the aorta and vena cava. - When the patient lies supine, the pregnant uterus can compress the aorta and vena cava (aortocaval compression). - Causes a significant decrease in blood return to the heart and, secondarily, in the forward flow of blood to the vital organs - If the pregnant patient is not in cardiac arrest, position her on her left side to relieve pressure on the great vessels. - If she is in cardiac arrest, if the top of the patient’s uterus (fundus) can be felt at or above the level of the umbilicus, perform manual displacement of the uterus to the patient’s left to relieve aortocaval compression while CPR is being performed. Grief Support for Family Members and Loved Ones CPR in the back of an ambulance is generally not effective. If the patient has not responded to treatment after 20 to 30 minutes (or longer), many protocols suggest discontinuing resuscitative efforts and not transporting. - This may create an uncomfortable situation at the scene. The following may make grief support in the field a little easier: - Use a compassionate and sensitive approach. - Appropriate and supportive care at the onset of grief can positively affect the family’s grieving process. - When death appears imminent and resuscitative efforts are unsuccessful, make the family members aware the patient is not responding to treatment. - Discuss with them what is happening so they may be better prepared. - Keep the family informed throughout the resuscitation process because it may also help them feel more in control. - Designate one provider to communicate the patient’s status to family members, so that information is streamlined. - Be concise and clear. - After resuscitation efforts have stopped, it is appropriate to tell the family the patient has died. - Avoid euphemisms such as “passed away” or “passed on,” because these expressions may be confusing or misinterpreted. - Law enforcement personnel will be responsible for determining whether the medical examiner should be notified. After resuscitation has stopped, other measures can be helpful: - Take the family to a quiet, private place. - Introduce yourself and anyone with you. - Use clear language and speak in a warm, 󳆫sensitive, and caring manner. - Try to exhibit calm, reassuring authority. - Use the patient’s name. - Use eye contact and appropriate touch. - Expect that family members will show emotion as they begin the grieving process. Be prepared for different reactions, including anger. - While you are still on scene, be supportive but do not hover. - Ask if a friend or family member can be called to come and help support them. - When you need to leave, turn the family over to someone else. - Some family members will want to see the deceased. - This may not be advisable in a medical examiner’s case, so law enforcement personnel will need to make that determination. - It is appropriate to make the body presentable, but follow local protocols regarding movement of the patient or removal of resuscitation equipment. Ensure that children are not ignored. Consider your own feelings in this stressful situation and make sure you seek assistance if needed. Education and Training The use of high-fidelity manikins for CPR training is encouraged. - If this is not an option, CPR devices that provide corrective feedback are preferred over devices that only provide voice prompts. CPR self-instruction through video and/or computer-based modules with hands-on practice is a reasonable alternative to instructor-led courses. - May facilitate frequent retraining Your agency should make an effort to identify potential patients at increased risk of cardiac arrest and educate their families to recognize cardiac arrest and to train them to perform compression-only CPR. QUIZ; 1. The AED gives a “no shock” message to a patient who is in cardiac arrest. What should you do? Resume chest compressions 2. A young male is unresponsive after overdosing on an opioid. He is not breathing and his pulse is weak. The EMT should immediately: ventilate with a BMV 3. A sign that is not a sudden severe upper airway obstruction is what? Forceful coughing 4. The impedance threshold device (ITD) may improve circulation during active compression-decompression CPR by? Limiting the amount of air that enters the lungs during the recoil phase between chest compressions, which results in negative intrathoracic pressure and improved cardiac filling. 5. What is positive pressure ventilation? airway pressure is applied at the patient's airway through an endotracheal or tracheostomy tube. The positive nature of the pressure causes the gas to flow into the lungs until the ventilator breath is terminated. a. If gastric distensions make positive pressure ventilation difficult, what should you do? Reposition patients airway 6. Most prehospital cardiac arrest occur as a result of what? A cardiac dysrhythmia