Hello and welcome to Chapter 14, BLS Resuscitation of the Emergency Care and Transportation of the Sick and Injured, 12th Edition. After you complete this chapter and the related coursework, you will have reviewed the Basic Life Support Procedures for Adults, Infant, and Children. Please note that BLS knowledge is a prerequisite for the course and that this chapter should serve as a review.
So as an introduction, the principles of basic life support were introduced in 1960, and since then, the specific techniques have been reviewed and revised regularly. The most recent review in 2020 was conducted by the International Liaison Committee for Resuscitation. Let's talk about some elements of BLS.
BLS is non-invasive emergency life-saving care that is used to treat medical conditions. They include airway obstructions, respiratory arrest, and cardiac arrest. It has a focus on ABCs. And what ABCs are is airway, which is the obstruction, breathing, example is respiratory arrest or circulation, cardiac arrest or severe bleeding.
If a patient is in cardiac arrest, then a CAB sequence. we use that, and that's the compressions airway breathing is used because chest compressions are essential and must be started as quickly as possible. Only seconds should pass the time you recognize that a BLS patient needs to have treatment. So permanent brain damage is possible if brain is without oxygen for more than four to six minutes. The figure on this slide illustrates the concept that time is critical.
for patients who are not breathing. If the brain is deprived of oxygen for more than four to six minutes, brain damage is possible. Okay, so let's talk about CPR. CPR reestablishes circulation and artificial ventilation in a patient who is not breathing and has no pulse. So CPR steps.
This is what you're going to do. So restore circulation by performing high quality chest compressions to circulate the blood. Then you're going to open the airway, restore breathing by providing rescue breathing.
You're going to administer two breaths over one second while you visualizing for chest rise and fall. Okay. So the figure on the slide demonstrates two EMS providers performing CPR.
BLF differs from ALS. advanced life support, which involves advanced procedures. And these procedures could include cardiac monitoring, administration of intravenous fluids and medications, use of advanced airway adjuncts, and while done correctly, BLS can maintain life for a short time until ALS measures can be started.
The figure on this slide illustrates the six links of the chain of survival. All right, so let's talk about those six links and the components of CPR, okay, the chain of survival. And the American Heart Association chain of survival includes, so all of these links have to be done, okay? So recognition and activation of the emergency response system, then immediate high-quality CPR.
We want rapid defibrillation, and then basic and advanced emergency services. advanced life support, and post-arrest care, and then recovery. If any one of those links in the chain is absent, the patient is more likely to die. Okay. All right.
So assessing the need for basic life support. It always begins by surveying the scene. You're going to complete the primary assessment as soon as possible in order to evaluate the patient's ABCs. First step is determining responsiveness. A responsive patient does not need CPR.
An unresponsive patient may or may not need CPR. This step should take no more than 10 seconds. The basic principles of BLS are the same for infants, children, and adults. Although cardiac arrest in adults usually occurs before respiratory arrest, the reverse is true in infants and children. In infants and children, it's usually respiratory that causes the cardiac arrest.
The figure on this slide demonstrates how to assess an unresponsive patient by first attempting to arouse him or her by tapping on the shoulder. Okay, so an automatic external defibrillation or an AED is a vital link in that chain of survival. The AED should be applied to a cardiac arrest patient as soon as possible. If you witness cardiac arrest, begin CPR and then apply. apply the AED as soon as possible.
AED use in children. So apply after the first five cycles. So this is the difference. We're going to do five cycles of CPR. So 30 seconds of five cycles and use pediatric size pads and a dose attenuating system.
If neither is available, then use the AED with adult size pads with an anterior purpose. posterior placement. Okay, so special situations such as pacemakers or implanted defibrillators, we're going to pace or place the electrodes at least one inch away from this device on wet patients or if the patient is in water, we want to pull them out and dry the skin before we attach the AED pads, okay?
And if the patient is in a small puddle of water or in snow, The AED can be used, but the patient's chest should be dried as much as possible. And then transdermal medication patches. Remember to remove those patches and wipe the skin to remove any residue prior to attaching the AED pad.
Positioning the patient. For CPR to be effective, the patient must be lying supine on a firm, flat surface. Ensure enough space around the patient for two rescuers to perform.
perform CPR. If possible, log roll the patient onto a long backboard. Check for breathing in a pulse. Quickly check for breathing in a pulse.
These assessments can occur simultaneously and take no longer than 10 seconds total. Visualize the chest for signs of breathing and then palpate for a crowded pulse. Provide external chest compressions.
So we're going to apply rhythmic pressure and relaxation to lower half of the sternum. Compression, squeeze the heart. It acts as a pump to circulate the blood. So avoid learning or avoid leaning on the chest in between chest compressions because we want complete recoil.
Proper hand and compression technique. You want to see skill drill 11-1 because injuries can be minimized by proper technique and hand placement. The figure on this slide illustrates the heart lies slightly to the left in the middle of the chest between the sternum and spine. And the figure on this slide illustrates the concepts of compression and relaxation. Okay, so compression and relaxation should be rhythmic and of equal duration, a one-to-one ratio.
So press on the sternum. It must be released so that the sternum can return to its normal resting position in between compressions. All right, so we started the CPR right away, and we've gotten the AED on as soon as we can.
The next step to this BLS concept is to go ahead and open the airway. So that's what we're going to talk about next. So we're going to open the airway in adults with a head tilt chin lift. We're going to remove any foreign materials if we found any in the mouth.
So we're going to use this for non-traumatic patients. Okay, so that head tilt, chin lift maneuver, and then the jaw thrust maneuver if we suspect any, any trauma at all. Okay, so if the patient is breathing adequately on his or her own and no signs of injury to the head, spine, hip, or pelvis, place him or her in the recovery position.
Okay. The figure on the slide demonstrates that recovery position, and the recovery position is used to maintain an open airway in an adequately breathing patient with a decreased level of consciousness who has no spinal injury. All right, so a lack of oxygen, which is known as hypoxia, combined with too much carbon dioxide in the blood, which is hypercarbia, is lethal. So we need to provide it.
deliberate ventilations that last for one second. If the patient is not breathing, ventilations can be given by one or two EMS providers. So we're going to use a barrier device such as a pocket mask, one-way valve, or a bag valve mask.
These devices are used to supply supplemental oxygen. when possible. Okay, the figure on this slide demonstrates using a barrier device when providing ventilations.
For a patient with a stoma, okay, so place the bag mask device or pocket mask device directly over the stoma. Artificial ventilations may result in gastric distension, so be ready to have a suction unit available in case the patient vomits. because gastric distension can cause vomiting.
So this figure on the slide demonstrates how a barrier device attaches to a stoma. The stoma connects the trachea directly to the skin. So you use a bag valve mask device or pocket mask device to ventilate the patient with a stoma. All right, so next let's talk about one rescuer adult CPR. Okay, so if there's one rescuer adult CPR, there are...
If we're providing CPR alone, we must provide a continuous cycle of 30 compressions followed by two ventilations. The ratio of compressions and ventilations, like I just said, is 30 to 2. Two rescuer adult CPR. So if there's two people, which is preferred, we'd rather have two people, it's preferred over one person, the rescuer who is doing the compressions can be switched. And this is less tiring and that facilitates effective chest compressions. So by switching rescuers during CPR, it's critical to maintain high quality compressions.
So it's recommended to switch positions every two minutes. All right, so now that we've talked about the one and two person CPR, we're going to talk about devices and techniques that can assist circulation, active compression and decompression CPR. So this involves compression of the chest and then actively pulling back up to its mechanical position or beyond. And it may increase the amount of blood that returns to the heart.
Then there's an impedance threshold device, ITD. And those are devices to limit the amount of air entering lungs during the recoil phase in between chest compressions. So the figure... First figure on the slide is an active compression device, and you can see that it's stuck on that sternum.
And then the second figure on the slide is an impedance threshold device. Okay, then there's mechanical piston devices, and that allows the rescuer to confirm the depth and rate of compressions. Okay.
and then there's low distributing band cpr and vest cpr then there's manual chest compressions manual chest compressions remain the standard of care however okay so this is a figure and it shows that load distributing band the auto pulse all right so we've talked about the adult cpr and now we're going to get into the infant and child cpr so like i said earlier in most cases cardiac arrest in infants and children follow respiratory risk, which triggers hypoxia and ischemia to the heart. So airway and breathing are the focus of pediatric basic life support. So causes of respiratory problems leading to cardiopulmonary arrest in children include there could be an injury, an infection of the respiratory tract, foreign body, submersion such as drowning.
It could have have been caused from electrocutions or poisonings or possibly sudden infant death syndrome, which is SIDS. All right. So when it comes to children, we're going to determine the responsiveness. So we're going to gently tap on the shoulder and speak loudly.
If you find an unresponsive apneic, so not breathing or pulseless child when you're alone and off duty, perform CPR for five cycles. So about two minutes. And then call the EMS system. So that is when you are alone and you find an unresponsive child.
Check for breathing and a pulse. So we're going to palpate the brachial artery in infants. The infant or child must be laying on a hard surface, of course, flat surface for effective chest compressions.
And we're going to use two fingers to compress an infant's chest. And if two rescuers are performing CPR on an infant, use the thumb. two thumb encircling technique to deliver chest compressions. In children, especially older than eight years old, you can use the heel of one or both hands to compress the chest. Follow the steps in skill drill 14-4 to perform the infant chest compressions.
And follow the steps in skill drill 14-5 to perform CPR in children between one year and the onset of puberty. All right. So in kids, of course, we talk a lot about airway and foreign body obstructions. And because it's very common, and as we mentioned earlier, usually...
in children and infant CPR, it's because of a respiratory issue. So we're going to place the unresponsive breathing child in the recovery position. And the two common techniques for manually opening the airway are modified for pediatric children.
Okay. So we're going to place a wedge of padding under the child's upper chest and shoulders to avoid partially obstructing their airway. We're going to provide rescue breathing. So if a child is not breathing, but has a pulse, then open the airway and deliver one breath every two to three seconds. And that's going to be about 12 to 20 breaths a minute.
Okay. If the child is not breathing and does not have a pulse, then we're going to do rescue breathing after every 30 compressions, 15 chest compressions if two rescuers are present. Okay. So if a child or small infant is breathing, then provide prompt transport. Allow the child to stay in whatever position is most comfortable.
And in a child with a trach tube in the neck, remove the mask from the bag and connect it directly to the trach tube to ventilate the child. The face mask with a one-way valve or a barrier device over the tracheostomy site can be used. Okay, so when are we going to interrupt CPR?
Hopefully when the pulse has returned, right? So, but CPR is... critical, right? And it's crucial. It's a life-saving procedure, but it only provides minimal circulation and ventilation until the patient can receive defibrillation, advanced life support treatment, and definitive care in the emergency department.
So no matter how well it's performed, CPR is rarely enough to save the patient's life. If advanced life support is not available at the scene, we must provide transport based on our local protocols, Continuing CPR on the way, consider requesting a rendezvous en route to the hospital with the ALS unit. Try not to interrupt CPR for more than a few seconds, especially when necessary, except when necessary. So chest compression fraction, the total percentage of time during a resuscitation attempt in which the chest compressions are not being performed. So try to maintain a chest compression fraction greater than 80%.
So to further explain that, you're going to take the total time that you are on scene with the patient in cardiac arrest and subtract the total time that you have been performing the chest compressions. Then the time left over is going to be the percentage of the resuscitation that is not performed. And that's going to be the chest compression fraction. Okay. All right.
So when not to start CPR. All right, so three general rules regarding when not to start CPR. So, of course, if the scene is unsafe.
Second, if the patient has obvious signs of death. Okay, so these include an absent of pulse and breathing, of course, along with any of one of the other following findings. Okay, so no pulse, not breathing, and if they have any one of these, you're not going to start CPR. All right.
So rigor mortis. Rigor mortis is stiffening of the body after death. Dependent lividity.
You'll also hear it's called liver mortis. Putrification. And that's when the body is decompensating or decomposition. Okay.
And then evidence of some non-survivable injury. So on this slide is an example of dependent lividity. And so what it does is this patient has been rolled so you could see the lividity so it's that purple discoloration of the back and basically what the patient was laying on the firm surface and the blood has pulled to the lowest the lowest because of gravity center of gravity all right so and then the third is if the patient and physician have previously agreed on do not resuscitate orders KSO DNR orders.
all right and when to stop CPR so once you begin continue until one of the following occurs and we use this mnemonic called stop okay so the S stands for patient starts breathing and has a pulse that would be wonderful T the patient is transferred to another provider of equal or higher training okay so another provider of equal higher training all right and the O is you are out of strength then the P is the physician directs you to discontinue. Just remember that in the O, the out of strength, it does not mean you're tired, but you are physically unable to continue. Okay. All right.
Let's talk about foreign body airway obstruction in the adults. So we want to recognize foreign body airway obstructions, but remember the most common is that relaxation of the throat muscles in an unresponsive patient. So the tongue, the tongue is very common.
So Or you could have vomited or regurgitated stomach contents. There could be blood or damaged tissue after an injury, dentures or foreign bodies such as food or small objects. So we want to recognize foreign body airway obstruction. And in adults, foreign body airway obstruction usually occurs during a meal. OK, but in children, that airway obstruction can occur during a meal or at play.
All right. So with a mild airway obstruction. We want the patient, so mild airway obstruction, the patient is going to be able to exchange an adequate amount of air, but still has some signs of respiratory stress. These mild airway obstructions, we're going to leave them alone.
And we're going to observe for signs of severe obstruction, just continue to reassess them. So mild airway, we're going to leave these patients alone. Responsive, so a sudden severe obstruction. is usually easy to recognize in responsive patients. The patient will suddenly be able to speak or cough.
They'll grasp his or her throat, usually turn cyanotic and make exaggerated efforts to breathe. Also, stridor might be present. So that's in responsive patients. Unresponsive patients suspect airway obstruction if maneuvers to open the airway and ventilate are ineffective. removing a foreign airway obstruction in adults.
So we're going to use the abdominal chest maneuver, and that's the Heimlich maneuver. And it's recommended in a patient in adults and children older than one year. So what this does is it creates an artificial cough. If the patient with a severe airway obstruction is unresponsive, then we're doing chest compressions. Okay, so responsive and children.
older than one year, we're doing the chest thrusts, which is the Heimlich maneuver. Once they go unresponsive, then we're going to do chest compressions. All right, so the figure on this slide displays how to perform an abdominal thrust maneuver in the responsive patient.
So that's the Heimlich. All right, instead of abdominal thrust maneuver, use chest thrusts for the following patients. And so you're moving farther up on the body.
And so that's women in advanced stages of pregnancy and also obese patients. You're going to move farther up, and those are the abdominal thrust. The figure on this slide displays how to perform chest thrusts on a responsive adult.
So see, you're moving up. So chest thrusts instead of abdominal thrusts on those patients. Responsive patients who become unresponsive. So the lower the patient, you want to lower the patient to the ground and call for help or send someone for help. And then we're going to do 30 chest compressions.
Do not check for a pulse before beginning chest compressions because we're doing this to create that, the power to knock out that foreign body airway obstruction. Okay, so open the airway and look in the mouth. If you see an object that can be easily removed, we're going to remove it with our finger.
and then attempt to ventilate. But if you do not see the object, we're going to just continue doing chest compressions. Repeat steps two and three until the obstruction is relieved or until the advanced life support providers take over.
So then in unresponsive patients, of course, when you come up, you determine unresponsiveness, you're checking for breathing and a pulse. If the pulse is present but breathing is absent, then we're opening the airway and attempting to ventilate. If the first ventilation does not provide visible chest rise and fall, then reposition the airway and attempt to ventilate. Both ventilation attempts do not produce visible chest rise.
Then perform 30 compressions. Then open the airway. Look in the mouth.
Attempt to carefully remove any visible object. Okay, so we've talked about adults. And now let's talk about children.
And we did say that airway obstruction is very common in infants and children. So in children who have signs and symptoms of an airway obstruction, Do not waste time trying to dislodge a foreign body. Administer supplemental oxygen if needed and immediately transport the child.
Okay, so that's signs and symptoms of an airway obstruction. As long as the patient can breathe, cough, or talk, do not interfere with his attempt to expel that foreign body. Administer supplemental oxygen if needed or tolerated and provide transport to the ED.
On a responsive standing or sitting child. perform Heimlich maneuver, but with less force than what you would use on an adult. Okay.
So an unresponsive child older than one year who has an airway obstruction is managed in the same manner as an adult. All right. So this figure is going to show you those abdominal thrusts. Remember those are responsive.
So, and then responsive infants. So we're going to perform back slaps and chest thrusts. which are also compressions.
And so this is going to, it's going to demonstrate this figure on how to perform those back blows and chest thrusts. So hold the infant face down with the body resting on the forearm. We're going to support the jaw and face of your hand and keep the head lower than the rest of the body. Give the infant back blows between the shoulder blades. So using the heel of your hand, give the infant five back quick chest thrusts.
So we're going to roll the patient over using two fingers placed on the lower half of the sternum. All right. So in unresponsive infants, we're going to begin chest compressions.
Do not check for a pulse before we start. Just like the adults, we're going to open the airway and look in the mouth. If we see an object that can be easily removed, then we're going to remove it. So if we do not see an object, then we're going to resume chest compressions.
We're going to continue the sequence. of chest compressions, opening the airway, and looking inside the mouth until the obstruction is relieved or advanced life support providers are taking over. All right, so when it comes to basic life support, there are some special circumstances that we need to talk about. Okay, so when it comes to opiate overdoses, EMTs may be allowed to administer Narcan. So we're going to...
Narcan to reverse the arrest. All right. And in the cardiac arrest in a pregnancy.
So priorities are to provide high quality CPR to relieve pressure of the aorta and vena cava. So if the pregnant patient is not in cardiac arrest, then position her on her left side to relieve pressure on those great vessels. All right.
So if she is in cardiac arrest and the top of the patient's uterus can be felt at or above the level of the umbilical umbilicus. Perform manual displacement of the uterus to the left, patient's left, to relieve atrial cavenal compression while CPR is being performed. Grief support for family members and loved ones.
Family members may experience a psychological crisis. that turns into a medical crisis. Okay, so family members and loved ones will remember this event in detail for the rest of their lives. So appropriate and supportive care at the onset of grief may positively affect the family's grieving process.
So keep the family informed throughout the resuscitative process. Designate one provider to communicate the patient's status to the family member. So you want to be concise and clear. After the resuscitation has stopped, these other measures can be helpful.
So 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 and use eye contact and appropriate touch.
So accept the family members will show emotion as they begin the grieving process. While you are still on scene, be supportive, but do not hover. And ask if a friend or family member can be called to come and support them.
When you need to leave, turn the family member over to someone. Ensure the child or children are not ignored. And see Chapter 2, Workforce Safety and Wellness, for a discussion of the emotional aspects of emergency care and stress management.
All right, so education and training for EMTs. So CPR skills can deteriorate over time. So we practice often using mannequin-based training.
CPR self-instruction through a video or a computer-based module with hands-on practice may be a reasonable alternative to an instructor-led course. Education and training for the public. So this is a major one, and you are a patient advocate. So not only are you responsible for providing the best care to the patient, but you must do your part to facilitate the training of laypeople.
In the... critical skills of CPR in the AAD operation. So if you are asked to train members of your community how to perform compressions only CPR, then you should consider it your professional responsibility and be willing to assist.
All right, so that concludes the chapter of basic life support, and we're going to go through some of the review questions to see how well we did. See if we can remember. All right, so brain damage is very likely in the brain that does not receive oxygen for how long? What do you think? Four to six minutes?
My goodness. Okay, permanent brain damage is very likely if the brain is without oxygen for longer than six minutes. All right, it can begin in four to six minutes. All right, so four to six minutes is that brain damage is possible at this stage. And then D, six to ten is...
is... brain damage is going to occur. All right, so which of the following sequence of events describes the advanced or American Heart Association chain of survival? So I know that we want to early access, we want to make sure that we see the, we get the call in early CPR, early defibrillation, early advanced care, and integrated post-arrest and recovery. So it looks like the C is our answer.
Right, all right, so the American Heart Association. determine the an ideal sequence of events okay all right let me set c number three so for cpr to be effective the patient must be on a flurum surface lying in the blank position all right so hopefully you guys know this one and it will be c supine c okay the pulse check should take how long do you guys think this will take so you Um, we know it's 10, but we don't want it to take more than 10. So five to 10. Okay. All right. So 10 seconds, that's too long. Artificial ventilation may result in the stomach becoming filled with air.
And this is called, it causes vomit, but it is gastric distension. Gastric distension is that air, and then it causes vomiting. The blank is a circumferential chest compression device composed of a constricting band and a backboard.
What do you guys think? So this is that load distributing band. There is a picture of it on the slide. And it basically is a circumferential chest compression device and it constricts.
Okay, so which of the following scenarios would warrant an interruption in CPR? So what about if we're tired? No. hysterical family member?
No. Horn honking? Probably not.
What about if we have to walk down steps? I think that that would probably be necessary, but only for as quick as possible, right? So walking down steps.
Okay, so once you begin CPR on the field, you must continue until one of the following events occurs. All right, so we know that it's not A. I think it's B.
So when we're transferred to another person who's trained or higher. So B, the T is the stop and it's a transfer acronym. Instead of abdominal thrust maneuver, you can use blank for women at advanced stages of pregnancy. We know it's the chest thrust. Abdominal maneuver for adults and children, however.
we're going to use the chest thrust or for the pregnancy or the severely obese okay Infants who have signs and symptoms of an airway obstruction, you should not waste time trying to dislodge the foreign body. You should intervene only if signs of blank develop. Severe airway obstruction. Okay, so severe airway obstruction is the answer.
All right. And this concludes the BLS chapter 14. Go ahead and if you enjoyed this lecture, subscribe to the channel. And we will continue to post the emergency care and transportation of the sick and injured chapters, 12th edition. Thank you.
Have a great night.