Transcript for:
Chapter 14: BLS Resuscitation

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 in 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 rest and cardiac arrest it has a focus on abcs and what abcs are is airway which is the obstruction breathing example is respiratory rest or circulation cardiac rest or severe bleeding if a patient is in cardiac risk 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 establishes this 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 gonna 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 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 or survival includes so all of these links have to be 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 okay the basic principles of bls are the same for infants children and adults although cardiac arrest in adults usually occurs before respiratory rest 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 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 then a dose attenuating system if neither is available then use the aed with adult-sized pads with an anterior 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's 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 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 the 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 lie 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 uh it must be released so that the sternum can return to its normal position a 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 um 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 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 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 bag mass device or pocket mass 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 all right so the figure on this slide demonstrates how a barrier device attaches to a stoma the stoma connects the trachea directly to the skin so you use a back valve mass device or pocket mass 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 if we're providing cpr alone we must provide a continuous cycle of 30 compressions followed by two ventilations okay the ratio of compressions and ventilations like i just said was is 30 to 2 to rescuer adult cpr so if there's two people which is preferred we'd rather have two people it's uh preferred over one person the rescuer who is doing the compressions can be switched and this uh is less tiring and facility that facilitates effective chest compressions so by switching rescuers during cpr it's critical to maintain high quality compressions so it's recommended the switch positions every two minutes all right so now that we've talked about the one and two persons cpr we're going to talk about devices and techniques that can assist circulation active compression and decompression cpr so this involves compressing 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 divided to limit the amount of air entering lungs during the recoil phase in between chest compressions so the figure first figure on this 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 always that allows the rescuer to confirm the depth and rate of compressions okay and then there's load 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 autopulse all right so we've talked about the adult cpr and now we're going to get into the infinite 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 and include there could be an injury an infection of the respiratory tract foreign body submersion such as drowning it could 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 apnic 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 on when you are alone and you find an unresponsive child check for breathing in a pulse so we're going to palpate the brachial artery and infants the infant our 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 and circling 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 this steps and 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 in infant cpr it's because of a respiratory issue so we're going to place the unresponsive breathing child in the recovery position and um the two common techniques for manually open 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 breast screws 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 and route to the hospital with the als unit okay 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 percent so to further explain that you're going to take the total time that you are on scene or with the patient and 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 death okay so these include an absence 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 um this patient has been rolled so you could see the libidity so it's that purple discoloration of the back and um basically what the patient was laying on the firm surface and the blood has pulled to the lowest um 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 okay so 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 a foreign body obstruction usually occurs during a meal okay 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 um so mild air obstruction the patient is going to be able to exchange a 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 response to 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 strider 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 adult 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 under and children older than one year so what this does is it creates an artificial cough if the patient with the severe airway obstruction is unresponsive then we're doing chest compressions okay so responsive and children older than one year we're doing the um 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 threats for the following patients and so you're moving farther up on the body um 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 the abdominal thrust okay the figure on this slide displays how to perform chest threats on an on a responsive adult so see you're moving you're moving up so chest rests instead of abdominal thrust on those patients okay 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 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 observe of 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 in 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 fries 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 uh 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 flush 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 thrust 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 uh 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 um special circumstances that we need to talk about okay so the 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 off 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 cavital 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 pain 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 okay so except 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 through a video or a computer-based module with hands-on practice may be 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 lay people in the critical skills of cpr and aed 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 um the chapter of uh basic life support and we're gonna go through some of the reviews uh 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 are you but what do you think four to six minutes oh my goodness okay permanent brain damage is very likely if the brain is without oxygen for longer than six minutes 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 p we get the call in early cpr early defibrillation early advanced care and integrated post rest and recovery so it looks like the c is our answer right all right so the american heart association uh determined 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 floor surface lying in the blank position all right so hopefully you guys know this one and it will be c supine okay the pulse check should take how long do you guys think this will take so um we know it's 10 but we don't want it to take more than ten so five to ten 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 dissension 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 um it's 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 a hysterical family member no uh horn honking probably not what about if we have the walk down steps i think that that would probably be necessary but only for as quick as possible right okay so walking down the 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 uh i think it's b so when we're transferred to another person who's trained or higher okay so b the t is the stop and it's a transfer acronym okay all right instead of abdominal thrust maneuver you can use blank for women in advanced stages of pregnancy we know it's the chest thrusts all right abdominal maneuver for adults and children however we're going to use the chest thrusts 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 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