BLS Resuscitation Lecture Notes

Chapter 14 BLS Resuscitation Unit Summary After students complete this chapter and the related course work, they will have reviewed the basic life support (BLS) procedures for adults, infants, and children. Please note that BLS knowledge is a prerequisite for the course and that this chapter should serve as a review. National EMS Education Standard Competencies Shock and Resuscitation Applies a fundamental knowledge of the causes, pathophysiology, and management of shock, respiratory failure or arrest, cardiac failure or arrest, and postresuscitation management. Knowledge Objectives 1. Explain the elements of basic life support (BLS), how it differs from advanced life support (ALS), and why BLS must be applied rapidly. (pp 557–559) 2. Explain the goals of cardiopulmonary resuscitation (CPR) and when it should be performed on a patient. (p 559) 3. Explain the components of CPR, the five links in the American Heart Association (AHA) chain of survival, and how each one relates to maximizing the survival of a patient. (pp 559–560) 4. Discuss guidelines for circumstances that require the use of an automated external defibrillator (AED) on both adult and pediatric patients experiencing cardiac arrest. (pp 561–562) 5. Explain three special situations related to the use of an AED. (p 562) 6. Describe the proper way to position an adult patient to receive BLS care. (pp 562– 563) 7. Describe the purpose of external chest compressions. (p 563) 8. Describe the two techniques EMTs may use to open an adult patient’s airway and the circumstances that would determine when each technique would be used. (pp 566–567) 9. Describe the recovery position and circumstances that would warrant its use, as well as situations in which it would be contraindicated. (pp 567–568) 1 10. Describe the process of providing artificial ventilations to an adult patient, ways to avoid gastric distention, and modifications required for a patient with a stoma. (pp 568–569) 11. Explain the steps in providing single-rescuer adult CPR. (pp 569–571) 12. Explain the steps in providing two-rescuer adult CPR, including the method for switching positions during the process. (pp 571–573) 13. Describe the different mechanical devices that are available to assist emergency care providers in delivering improved circulatory efforts during CPR. (pp 573, 575–577) 14. Describe the different possible causes of cardiopulmonary arrest in children. (p 577) 15. Explain the four steps of pediatric BLS procedures and how they differ from BLS procedures used in an adult patient. (pp 577–584) 16. Describe the ethical issues related to patient resuscitation, including examples of when not to start CPR on a patient. (pp 584–586) 17. Explain the various factors involved in the decision to stop CPR after it has been started on a patient. (pp 586–587) 18. Explain common causes of foreign body airway obstruction in both children and adults and how to distinguish mild or partial airway obstruction from complete airway obstruction. (pp 587–588) 19. Describe the different methods for removing a foreign body airway obstruction in an infant, child, and adult, including the procedure for a patient with an obstruction who becomes unresponsive. (pp 588–593) 20. Discuss how to provide grief support for a patient’s family members and loved ones after resuscitation has ended. (pp 594–595) 21. Discuss the importance of frequent CPR training for EMTs, as well as public education programs that teach compression-only CPR. (p 595) Skills Objectives 1. Demonstrate how to position an unresponsive adult for CPR. (pp 562–563) 2. Demonstrate how to check for a pulse at the carotid artery in an unresponsive child or adult. (p 563) 3. Demonstrate how to perform external chest compressions on an adult. (pp 563– 565, Skill Drill 14-1) 4. Demonstrate how to perform a head tilt–chin lift maneuver on an adult. (p 566) 5. Demonstrate how to perform a jaw-thrust maneuver on an adult. (pp 566–567) 6. Demonstrate how to place a patient in the recovery position. (pp 567–568) 7. Demonstrate how to perform rescue breathing in an adult. (p 568) 2 8. Demonstrate how to perform one-rescuer adult CPR. (pp 569–571, Skill Drill 142) 9. Demonstrate how to perform two-rescuer adult CPR. (pp 571–573, Skill Drill 143) 10. Demonstrate the use of mechanical devices that assist emergency responders in delivering improved circulatory efforts during CPR. (pp 573–577) 11. Demonstrate how to check for a pulse at the brachial artery in an unresponsive infant (p 579) 12. Demonstrate how to perform external chest compressions on an infant. (pp 579– 580, Skill Drill 14-4) 13. Demonstrate how to perform CPR in a child who is between 1 year of age and the onset of puberty. (pp 580–582, Skill Drill 14-5) 14. Demonstrate how to perform a head tilt–chin lift maneuver on a pediatric patient. (p 582) 15. Demonstrate how to perform a jaw-thrust maneuver on a pediatric patient. (pp 582–583) 16. Demonstrate how to perform rescue breathing on a child. (p 583) 17. Demonstrate how to perform rescue breathing on an infant. (p 583) 18. Demonstrate how to remove a foreign body airway obstruction in a responsive adult patient using abdominal thrusts (Heimlich maneuver). (p 588) 19. Demonstrate how to remove a foreign body airway obstruction in a responsive pregnant or obese patient using chest thrusts. (p 588–591) 20. Demonstrate how to remove a foreign body airway obstruction in a responsive child older than 1 year using abdominal thrusts (Heimlich maneuver). (pp 590– 591) 21. Demonstrate how to remove a foreign body airway obstruction in an unresponsive child. (pp 591–592, Skill Drill 14-6) 22. Demonstrate how to remove a foreign body airway obstruction in an infant. (pp 591, 593) Readings and Preparation Review all instructional materials including Emergency Care and Transportation of the Sick and Injured, Twelfth Edition, Chapter 14, and all related presentation support materials. • Review current American Heart Association standards for basic life support (CPR) for adults, children, and infants. 3 Support Materials • Lecture PowerPoint presentation • Skill Drill PowerPoint presentations o Skill Drill 14-1, Performing Chest Compressions PowerPoint presentation o Skill Drill 14-2, Performing One-Rescuer Adult CPR PowerPoint presentation o Skill Drill 14-3, Performing Two-Rescuer Adult CPR PowerPoint presentation o Skill Drill 14-4, Performing Infant Chest Compressions PowerPoint presentation o Skill Drill 14-5, Performing CPR on a Child PowerPoint presentation o Skill Drill 14-6, Removing a Foreign Body Airway Obstruction in an Unresponsive Child PowerPoint presentation • Equipment needed to perform the psychomotor skills presented in this chapter. • Skill Evaluation Sheets o Skill Drill 14-1, Performing Chest Compressions o Skill Drill 14-2, Performing One-Rescuer Adult CPR o Skill Drill 14-3, Performing Two-Rescuer Adult CPR o Skill Drill 14-4, Performing Infant Chest Compressions o Skill Drill 14-5, Performing CPR on a Child o Skill Drill 14-6, Removing a Foreign Body Airway Obstruction in an Unresponsive Child Enhancements • Direct students to visit Navigate. • Contact a local survivor of cardiac arrest and ask this person to give a brief presentation to the students on the events that transpired, explaining how the prehospital providers made a difference in his or her life. • Contact the local American Heart Association representative and ask him or her to discuss the statistics relating to cardiac arrest for your local jurisdiction. • Content connections: Students should be able to relate cardiac arrest to its specific causes, such as sudden cardiac arrest, drowning, and overdoses. Specific causes of cardiac arrest are discussed in depth in their respective chapters. • Cultural considerations: Students need to be made aware of the religious or cultural beliefs in the setting of resuscitation—specifically, how certain cultural groups (such as Native Americans) wish to have a prayer ceremony prior to the victim being transported to the hospital. 4 Teaching Tips • BLS (CPR) is a prerequisite to the National EMS Educations Standards; therefore, this lesson should serve as a review. However, the allotted time allows for presentation of the certified course if necessary. • Several skills listed for this lesson can be found in Chapter 35, “Pediatric Emergencies.” They are listed here as they relate to BLS review for infants and children. • Use of the AED is covered in Chapter 17, “Cardiovascular Emergencies.” Unit Activities Writing assignments: Assign students to complete a research paper on the topic of controversies in the administration of positive pressure ventilation to patients suffering from sudden cardiac arrest. Does current research support or discount the administration of positive pressure ventilation versus free-flowing oxygen? Student presentations: Ask students to give a presentation to the class discussing one link in the cardiac chain of survival. Group activities: Ask each group to develop a cardiac arrest scenario and practice the management for their scenario. Visual thinking: Present the students with equipment, such as masks, oral and nasal airways, and bag-mask devices. Ask them to describe the indications and contraindications of each device. Pre-Lecture You are the Provider “You are the Provider” is a progressive case study that encourages critical thinking skills. Instructor Directions 1. Direct students to read the “You are the Provider” scenario found throughout Chapter 14. 2. You may wish to assign students to a partner or a group. Direct them to review the discussion questions at the end of the scenario and prepare a response to each question. Facilitate a class dialogue centered on the discussion questions and the Patient Care Report. 3. You may also use this as an individual activity and ask students to turn in their comments on a separate piece of paper. Lecture 5 I. Introduction A. The principles of basic life support (BLS) were introduced in 1960. B. Since then, the specific techniques have been reviewed and revised regularly. C. The goal is to produce the best recommendations possible given the available scientific evidence and to maximize the chance of successful resuscitation. D. Reviews are conducted ad published conducted by the International Liaison Committee on Resuscitation (ILCOR). II. Elements of BLS A. BLS is noninvasive emergency life-saving care that is used to treat medical conditions, including: 1. Airway obstruction 2. Respiratory arrest 3. Cardiac arrest B. Focus is on the ABCs C. If the patient is in cardiac arrest, then a CAB sequence is used because chest compressions are essential and must be started as quickly as possible. D. Only seconds should pass between the time you recognize that a patient needs BLS and the start of treatment. 1. Permanent brain damage is possible if brain is without oxygen for more than 4 to 6 minutes. E. Cardiopulmonary resuscitation (CPR) 1. Reestablishes circulation and artificial ventilation in a patient who is not breathing and has no pulse 2. CPR steps: a. Restore circulation by performing high-quality chest compressions to circulate the blood. b. Open the airway. c. Restore breathing by providing rescue breathing. i. Administer two breaths while visualizing for chest rise. F. BLS differs from advanced life support (ALS), which involves advanced procedures such as: 1. Cardiac monitoring 2. Administration of intravenous (IV) fluids and medications 3. Use of advanced airway adjuncts 6 G. When done correctly, BLS can maintain life for a short time until ALS measures can be started. III. The Components of CPR A. Chain of survival 1. The American Heart Association’s (AHA) chain of survival: a. b. c. d. e. f. Recognition and activation of the emergency response system Immediate, high-quality CPR Rapid defibrillation Basic and advanced emergency medical services ALS and postarrest care Recovery B. If any one of the links in the chain is absent, the patient is more likely to die. IV. Assessing the Need for BLS A. Always begin by surveying the scene. B. Complete the primary assessment as soon as possible in order to evaluate the patient’s ABCs. 1. First step is determining unresponsiveness: a. A responsive patient does not need CPR. b. An unresponsive patient may or may not need CPR. 2. This step should take no more than 10 seconds. C. The basic principles of BLS are the same for infants, children, and adults. D. Although cardiac arrest in adults usually occurs before respiratory arrest, the reverse is true in infants and children. V. Automated External Defibrillation A. AED use is a vital link in the chain of survival. B. AED should be applied to a cardiac arrest patient as soon as available. C. If you witness cardiac arrest, begin CPR and apply the AED as soon as available. D. AED use in children 1. Use pediatric-size pads and a dose attenuating system. 2. Apply after the first five cycles of CPR. 3. If adult-size AED pads are used on an infant or small child, do not cut the pads to adjust the size. Use the anterior-posterior placement. 7 E. Special situations 1. Pacemakers and implanted defibrillators a. Place electrodes at least 1 inch (2.5 cm) away from the device. 2. Wet patients a. If the patient is in water, pull the patient out and dry the skin before attaching the AED pads. b. If the patient is in a small puddle of water or in the snow, the AED can be used, but the patient’s chest should be dried as much as possible. 3. Transdermal medication patches a. Remove the patch and wipe the skin to remove any residue prior to attaching the AED pad. VI. Positioning the Patient A. For CPR to be effective, the patient must be lying supine on a firm, flat surface. 1. Ensure enough space around the patient for two rescuers to perform CPR. 2. If possible, log roll the patient onto a long backboard. VII. Check for Breathing and a Pulse A. Quickly check for breathing and a pulse simultaneously. 1. These assessments occur simultaneously and take no longer than 10 seconds total. a. Visualize the chest for signs of breathing while palpating for a carotid pulse. B. Provide external chest compressions. 1. Apply rhythmic pressure and relaxation to the lower half of the sternum. 2. Compressions squeeze the heart, acting as a pump to circulate blood. 3. Avoid leaning on the chest in between chest compressions. C. Proper hand position and compression technique 1. See Skill Drill 14-1. 2. Injuries can be minimized by proper technique and hand placement. VIII. Opening the Airway and Providing Artificial Ventilation A. Opening the airway in adults 1. Head tilt–chin lift maneuver a. Remove any foreign materials in the mouth. 8 2. Jaw-thrust maneuver B. If the patient is breathing adequately on his or her own and has no signs of injury to the spine, hip, or pelvis, place him or her in the recovery position. C. A lack of oxygen (hypoxia), combined with too much carbon dioxide in the blood (hypercarbia), is lethal. 1. Provide slow, deliberate ventilations that last 1 second. D. If patient is not breathing, ventilations can be given by one or two EMS providers. 1. Use a barrier device, such as a pocket mask, one-way valve, or bag-mask device. 2. Use devices that supply supplemental oxygen when possible. E. For a patient with a stoma, place a bag-mask device or pocket mask device directly over the stoma. F. Artificial ventilation may result in gastric distention. 1. Have a suction unit available in case the patient vomits. IX. One-Rescuer Adult CPR A. When providing CPR alone, you must provide a continuous cycle of 30 chest compressions followed by 2 artificial ventilations (see Skill Drill 14-2). 1. The ratio of compressions to ventilations is 30:2. X. Two-Rescuer Adult CPR A. Always preferable to one-rescuer CPR (see Skill Drill 14-3) 1. Less tiring and facilitates effective chest compressions B. Switching rescuers during CPR is critical to maintain high-quality compressions. 1. It is recommended to switch positions every 2 minutes. XI. Devices and Techniques to Assist Circulation A. Active compression-decompression CPR 1. Involves compressing the chest and then actively pulling it back up to its neutral position or beyond 2. May increase the amount of blood returning to the heart B. Impedance threshold device (ITD) 1. Designed to limit the air entering the lungs during the recoil phase between chest compressions 2. Not currently recommended for use with conventional CPR 9 C. Mechanical piston device 1. Allows the rescuer to configure the depth and rate of compressions D. Load-distributing band CPR or vest CPR E. Manual chest compressions remain the standard of care. XII. Infant and Child CPR A. In most cases, cardiac arrest in infants and children follows respiratory arrest, which triggers hypoxia and ischemia of the heart. 1. Airway and breathing are the focus of pediatric BLS. B. Causes of respiratory problems leading to cardiopulmonary arrest in children 1. Injury, both blunt and penetrating 2. Infections of the respiratory tract or another organ system (croup, epiglottitis) 3. Foreign body in the airway 4. Submersion (drowning) 5. Electrocution 6. Poisoning or drug overdose 7. Sudden infant death syndrome C. Determining responsiveness 1. Gently tap child on shoulder and speak loudly. a. If you find an unresponsive, apneic, pulseless child, while alone and off duty, perform CPR for 5 cycles (about 2 minutes) and then call the EMS system. D. Check for breathing and a pulse. 1. Palpate the brachial artery in infants. 2. The infant or child must be lying on a hard, flat surface for effective chest compressions. 3. Only use two fingers to compress an infant’s chest. 4. If two rescuers are performing CPR on an infant, use the two-thumb-encirclinghands technique to deliver chest compressions. 5. In children, especially those older than 8 years, you can use the heel of one or both hands to compress the chest. 6. Follow the steps in Skill Drill 14-4 to perform infant chest compressions. 7. Follow the steps in Skill Drill 14-5 for performing CPR in children between 1 year and the onset of puberty. E. Airway 1. Foreign body obstruction in children is common. 10