so now we're up to chapter 14 which is bls resuscitation or basic life support resuscitation again we've talked about shock and resuscitation excuse me recent shock but now we have to talk about shock and resuscitation so the principles of basic life support or bls were only really introduced in the 1960s early 1960s so the cpr that you know today is hasn't been around that long uh historically they used to try different methods to to bring people back to life uh they used to whip them with nettles uh like a a sticker bush they used to uh take the blacksmith bellows and put that in their rectum to try to blow life back into them all kinds of different crazy things but the cpr that you're aware of today really only started in the 1960s so it's been reviewed and revised regularly it's typically on a five-year schedule that it's reviewed but it's been really enhanced and improved since the 1960 or the first time that they ever did cardio resuscitation so the most recent review was 2020 and again without saying it was we're really saying the american heart association in most ems systems in most hospitals american heart association health care provider is the level of cpr that you want to get not just cpr with the aed but you want to get health care provider cpr so there's it's a non-invasive emergency life care we use it to treat medical conditions including airway obstruction respiratory arrest and cardiac arrest we're going to focus really on the abcs again and that's part of your assessment airway breathing and circulation ideally only seconds should pass between the time you recognize a patient needs bls basic life support in the start of treatment really you should spend less than 10 seconds uh assessing your patient brain damage can occur if they if the brain does not have oxygen within four to six minutes it's critical that we get started with our cpr if if it's more than 10 minutes you're going to have irreversible brain damage so we really want to start it before that four to six minute time mark hits cardiopulmonary resuscitation or cpr so we're going to re-establish hopefully circulation and artificial ventilation a patient who is not breathing has no pulse so basically we're going to provide the mechanical functions of that body that's not working cpr we're going to restore circulation through doing chest compressions we're going to open up the airway and we're going to restore breathing through rescue breathing so again here they're going to be doing cpr and rescue breathing with a bbm that has been attached to oxygen so bls basic life support really differs from als or the advanced life support so as a paramedic the things that i will do will be a little bit different it's going to be more advanced so like the cardiac monitor we're going to be actually as paramedics looking at the cardiac rhythm and treating it versus an aed that does that for you as a paramedic we're going to start ivs and we can get fluids and medications through the iv to help uh hopefully restore this heart beating and then we can do advanced airway adjuncts to help ensure that we get proper ventilation and oxygenation to the patients so this is the chain of survival early recognition and activation of the ems starting high quality cpr early defibrillation basic and advanced ems als and post arrest and then there's a recovery phase as well which we just went through all of these in the chain of survival and we really truly are the the majority of this chain of survival in ems so always begin by surveying the scene to make sure the scene is safe before you provide care complete your assessment as soon as possible evaluate the abcs looking at the airway open the airway check for breathing check for a pulse if not start cpr and again it should take less than 10 seconds the principles of bls are the same for infants adults and children um although adults usually uh um arrest and yeah sorry although cardiac arrest adults usually occurs before respiratory arrest the reverse is true in infants and children so infants and children usually go into cardiac arrest because they stop breathing for some reason we as adults we go into cardiac arrest because of age disease processes uh eating too much mcdonald's smoking that kind of stuff so again you establish unresponsiveness by tapping on their shoulders and shouting at them sir sir sir can you hear me using an aed or automatic external defibrillator is a really a vital link in that chain of survival for the adult especially um it should be used as soon as it's available you don't have to wait until you're done with your chest compressions at the next break put it on as soon as possible because adults really need this defibrillation if you witness a cardiac arrest begin cpr put the aed on as soon as it's available and use it the faster you can defibrillate that patient the better it is in children there's a difference we're gonna do five cycles of cpr before we use the aed and again they've gone into cardiac arrest because of a respiratory problem not a cardiac problem with the pediatric aed we want to use pediatric pads there's no such thing as infant pads it's only child pads um again according to american heart and all the studies if you don't have pediatric pads available you can use the adult pads on the child it's a little more energy than they need but the theory is there's more energies better than no energy special situations pacemakers and implanted defibrillators those are the devices implanted under the skin uh which could help the a person's heart either by speeding it up or actually defibrillating it internally um they're small like a deck of cards or a small circle underneath their skin we just want to make sure we don't put our defibrillation pads on top of those wet patients we want to dry them we don't want the electricity to go through the water on top of their skin we want it to go through their skin and into their heart for defibrillation and then transdermal medication patches those are the medication patches are applied to the skin with those we want to take them off wipe the area and then put our pad down if it's in the location where we want to put our pads for cpr now they have to be on a supine on a firm flat surface for those of us in ems we get dispatched and respond to somebody's home for somebody in cardiac arrest a lot of times they're in bed we need to get them out of that bed and on the floor or put them on a backboard whatever we can do to make it a flat firm surface and again you want to get enough room for two people to perform cpr sometimes your person goes into cardiac arrest in these tiny bathrooms we need to pull them out of that bathroom and get them out into an area where we can work on them check for a pulse when you're checking for a pulse for somebody who's unresponsive we always check for a carotid pulse with the carotid pulse as we're checking and feeling for that pulse we also want to look for the chest rising and falling as they breathe when we're doing our external chest compressions we want to be on the lower half of the sternum we want to compress or basically squeeze the heart and we're acting like a pump or we're actually pumping the blood through the body and we want to avoid leaning on the chest because between compressions because we want that chest to fully recoil up to allow it to fill with blood before we push down again to squeeze it out that's the control re recoil between compressions putting your hands in the proper position is crucial too you want to be in the lower half of the sternum or the breastbone and then injuries can minimize be minimized by proper technique and hand placement if your hands are off and you're more on the ribs than on the sternum you might break ribs on somebody now this is so controversial me saying this because i have friends that'll say it you're not doing good cpr till you break ribs and that's not necessarily always true yes it may be true in our elderly people who we typically are doing cpr on but you're not nor should you break ribs on a younger person or child or infant the ribs give yet so if you do break ribs on a younger person that you should not be breaking ribs on it's because you're pushing more sideways than straight down that's what the studies have shown and again why we push on the sternum is because that is the firm surface that's above the heart so when you push down on the sternum you're basically squishing the heart between the sternum and your spine so again your your compression and duration excuse me and it equals your duration so you push down and you're up down and up down and up letting that chest fully recoil between compressions we open the airway doing a head tilt chin lift maneuver and your hand in the forehead hand underneath the chin if you suspect a spinal injury we do the jaw thrust maneuver so many people don't know how to do this as an emt you have to know how to do this if the patient is adequately breathing and there's no signs of injury to the head spine hip or pelvis place them in the recovery position so if they're breathing on their own but they're just unconscious and you don't suspect a head neck or back uh injury roll them on their side into the recovery position that's this position you notice how his right leg kind of keeps him from rolling over onto his stomach so the combination of lack of oxygen and too much carbon dioxide in the blood is lethal so if the patient's not breathing ventilations can be given by one or two ems providers using a barrier device you really want to be careful by using this barrier device better yet you should just use a bag mask device or bag valve mass device doing mouth-to-mouth ventilations has really shown not to be a good thing to do i've had doctors tell me there's no cases of anyone ever getting a disease off of somebody while doing cpr with mouth to mouth but and then i always have to say well doc that may be true but the thought of having somebody throw up into my mouth is not a pleasant one so if they have a stoma we kind of talked about this earlier you could use the bag mask or pocket mask device over the stoma uh again we want to be careful that if we bag too hard and too fast it's going to make air go into their stomach so we want to be careful with that and then have your suction unit ready because a lot of times people will vomit during cpr there's the stoma there's the bvm using it right over the stoma single rescuer doing both chest compressions and ventilations we do 30 compressions in two breaths when we're doing one rescuer adult cpr 30 compressions and two breaths we really like to do two-person cpr because it's less tiring and it's you have more effective chest compressions and then we switch compressors every two minutes so you do two minutes of cpr and after two minutes you're going to be tired whether you realize it or not and then i'll take over for two minutes while you rest while you're resting you're also delivering the breaths so we want to have an active compression decompression so and we want to make sure that the chest fully recoils that's really super important to make sure that the chest fully recoils between compressions so that we can do more and better effective cpr there are some devices that kind of help you with this one is the impedance threshold device it really does limit the air entering the lungs during the recoil phase between between compressions so we the lungs aren't getting hyperinflated if you will so that if the lungs get hyperinflated it puts pressure on the heart so we don't want that pressure so this helps alleviate that pressure and that's the device on the right that one is called the rescue it's rest q pod i know it sounds kind of weird rescue pod it's a disposable one use only kind of device the the drawback for using the rescue pod is that it's expensive now the device on the left is also made by the same company and it's kind of like a a big suction cup if you will when doing cpr and when you're pushed down it it does what it's supposed to do but then when you let the chest recoil it kind of pulls the chest up when you come back up to the top so you're almost kind of like pulling the chest up pushing the chest down pulling it up pushing down and that is to make uh the heart fill with blood better and to push it out better so it's i've never used one but it's it's devices designed to do better cpr now we have mechanical devices for cpr there's either a i call it a vest like device or there's a piston device so there if you're familiar with the piston device that's called a lucas and then the best device is the uh i always have a hard time remembering the name of it uh but i'll show you a picture here in a second but the the vest type device is a little bit different than how they work they both work great don't get me wrong they're fantastic they never get tired they do it a great depth of compressions all the time they let the chest fully recoil every time you cannot get any better cpr when you use these devices and this is the but the device uh that's layered all this is more of the best type device that you kind of put around your patient and the whole chest is kind of compressed or squeezed versus a piston type device which is just a a piston that just goes up and down on top of your sternum so either one works really well this one's a little bit more expensive than the lucas when we talk about cardiac arrest and infants and children it's usually because they've stopped breathing so we really need to focus our skills on the infant or child and cardiac arrest on good high quality cpr defibrillations for adults really truly infants and children need good high quality cpr why do they stop breathing well sometimes it's a trauma injury infections maybe they've choked on something with a foreign body maybe they drown maybe they've been electrocuted maybe they've gotten into mom or dads or grabbing grandma's medicine and they've got an overdose or poisoning and a lot of your infants are going to be because of sids that sudden infant death syndrome another way to start the cpr instead of tapping and shouting at them we're going to speak loudly we don't need to shout at that infant if that infant is truly sleeping we're going to scare the crap out of them so again tap their shoulder tap the bottom of their feet we check for breathing in a pulse especially in infants we check for a pulse in the brachial in the arm in the children we check for a carotid pulse and again we should not take longer than 10 seconds if you think a foreign body obstruction is there again that's where we have to place them in place an unresponsive breathing child in a recovery position yeah if they're breathing recover but if they're foreign body obstruction we need to start cpr if they're unconscious if they're choking we have different ways of of opening up the airway and it says place a wedge under the upper chest and shoulders one supine the problem with infants and children laying flat on the ground is the back of their head is pretty prominent and when they lay flat on the back on their back and their heads bigger it kind of pushes their chin down onto their chest kind of blocking their airway a little bit if you put a wedge or some towels under their shoulder it's gonna prop their head open better provide rescue breathing we're gonna give one breath every two to three seconds with an infant or child so if the only way we do rescue breathing is if they have a pulse but they're just not breathing if they're not breathing in no pulse then we have to start cpr so again if they have a pulse but they're just not breathing it's one breath every two to three seconds and if they're not breathing in there's no pulse we start cpr again if no als is available transport consider requesting als rendezvous enroute to hospital als is very important when it comes to cardiac arrest there's so many more medications i can use and and airway tools there's a lot of different things a paramedic can do versus an emt again call als for a cardiac arrest absolutely don't interrupt cpr for more than 10 seconds we typically say never interrupt cpr for more than 10 seconds no more than 10 seconds chest compression compression fraction it's basically the total time during the resuscitation in which you're doing cpr and so if you do cpr and you do 60 of your time is done doing chest compressions you're doing good cpr you know 80 obviously would be better but so the longer you're off the chest the worse it is for the patient if the scene's not safe we're not going to start cpr leave maybe it's a toxic chemical cloud or whatever and it's not safe for you to even start cpr maybe it's a shooting and then the bad guys not caught yet it's not safe don't start cpr you also don't start cpr if there's obvious signs of death rigor mortis is one uh lividity uh is another um putrefaction or decomposition of the body evidence of a non-survivable injury their head is cut off we're not going to start cpr this is a an interesting picture showing liquidity it's the pooling of the blood in the lower areas of the body so this person was obviously laying on their back when they died and it's that that purple discoloration the parts where it's white like the buttocks and and his shoulder blades they're white because they were in firm contact with the the bed or the floor it's the other parts where the blood just kind of pulled if a patient and physician have previously agreed on a do not resuscitate order you don't do cpr either but you have to have a valid dnr do not resuscitate order just having somebody tattoo the letters dnr in their chest does not work for this uh it it also doesn't work if the if the spouse says don't do cpr they don't they don't want it we still have to do it the only way you don't is if they have that valid dnr order it's a piece of paper once you start cpr uh continue until i've never heard this this put this way until s the patient starts breathing and has a pulse t the patient's transferred to the the paramedics or the hospital oh you're out of strength uh let's say you're doing cpr out in the woods on grandpa during hunting season and you you just do it until you can't do it anymore or p the physician tells you to stop and that might be on somebody the physician telling you at the hospital or they you talk to the physician on your radio or telephone while you're in the person's residence and the doctor says hey go ahead and stop foreign body airway obstruction in adults again the obstruction might be caused by relaxation of the throat muscles and then the tongue kind of falls back maybe they vomited uh or regurgitated this whatever again beer and pizza in our world uh blood damage tissue dentures loose dentures uh foreign bodies maybe some steak or something in adults it usually occurs during a meal with children occurs during a meal or when they're out playing a patient with mild airway obstruction is able to exchange air but with signs of respiratory distress we just want to encourage them to cough sudden severe obstruction that's easy to recognize uh hopefully that they should be putting their hands at their throat and they should be making some type of indication that they cannot breathe in unresponsive patients we open up the airway and we try to ventilate and if we're not effective reposition ahead and try to ventilate again if air doesn't go in we start cpr through the process of cpr we should still be able to push that object out if possible and if we don't at least we're still circulating the good blood in the body through our chest compressions the heimlich maneuver we use that on anybody over the age of one and they're conscious so that's the heimlich maneuver dr heimlich figured this out you go right above their belly button and you do it as hard as you can until it comes out or the person goes out if they're pregnant or really obese and you can't get your arms around their belly go up on their chest where you would do your chest compressions on the sternum up high on the sternum if they're unresponsive we check for breathing in a pulse if the pulse is present and the breathing is happening we try to ventilate if you can't get the air in after two attempts do 30 chest compressions and always look in the mouth before you blow again if you see it reach in there pull it out if you don't see it go back to the chest compressions again it's a really common problem in infants and children because especially infants and small children they put everything in their mouth so having an obstructed airway is very common um if there are any signs and symptoms airway obstruction that says do not waste time uh we're trying to get that out we need to get it out as quickly as possible on a responsive standing or sitting child we do the heimlich maneuver if they're unresponsive we do it the same way as the adult we open up the airway we check for breathing if they're not we try to ventilate if not we do 30 compressions and we come back and check the airway again so if they're unconscious we do cpr with the only difference being we look in their mouth before we blow heimlich maneuver over the age of one i know a lot of people go well i have a 13 month old that's really small i always say we do what we got to do to get it out um you know i i'll experiment on my kids you experiment on your kids but as an ems professional when i get there i'm not going to experiment on your child i'm going to do what i'm trained to do and that's over the age of one i'm going to do the heimlich maneuver in responsive infants don't use abdominal thrusts because there's in children and adults we have abdominal muscles well they don't in infants we're going to do something called back slaps and chest rusts and what you do is you're going to be slapping their back up high by the shoulder blades you're going to do it five times and then you're going to sandwich them and flip them over onto their back and you're going to do chest rust five times right where you do cpr so when you do your cpr class you need to practice these maneuvers because this is kind of involved you want to do it hard enough to get the object out i always say if you don't do it hard enough you're really going to hurt that kid because that kid's going to stop breathing well in reality they're not breathing right now they're going to go unconscious so if you don't do it hard enough they are definitely going to go unconscious in unresponsive infants begin cpr do not check for a pulse before starting compressions and again look in the airway before you blow if you see it get it out if you don't see it do more chest compressions some special circumstances that you learn about in cpr class and as an emt the opioid overdose we still want to do high quality cpr but during cpr we can add in that naloxone our narcan administration but we still need to do high quality cpr cpr in pregnancy so if you have enough help like you have three people one person could be doing chest compression one person could be bagging a third person could actually help push that that pregnant female stomach to the left so it comes off the aorta and vena cava which will help blood flow return to the heart so again if you have enough help you might want to try that talks about uh grief support for family members and loved ones so family members this is going to be you know you're part of the worst time in that person's life um so again that's going to be a horrible situation and we can make it worse or we can make it better a lot of times we will work a cardiac arrest in the person's house until a we either bring them back to life or b we call them dead so that's becoming more and more of the practice and ems um so you want to keep the family involved and informed throughout this whole process tell them you know while cpr is going on you could have the partner or the person not doing cpr get with the family say this is what we're doing his heart's not working we're doing cpr we're put you know pushing on his heart to circulate the blood or bro blowing into him to give him some oxygen um and you want to tell them you know if you get the order to stop cpr from the doctor you you want to tell the family members you know we're gonna at the we're gonna stop cpr 30 and we're not going to do any more you really have to get them involved and keep them informed sometimes they'll be angry but i found that for the most part they really do accept it pretty well after resuscitation is stopped take them into the living room sit down with them call somebody for them call their pastor call the family members you know it's not about the person in the kitchen on the floor anymore it's about the family members don't use medical terms with them talk to them in clear language this is you know you have to be sensitive to this situation um don't keep saying to the the patient the patient the patient use the person's name um and this is a really a good time may be a good time i should say to actually you know hold their hand or something like that but you want to be you want to be sincere don't be fake with this um expect emotions they're going gonna cry they're gonna scream this is gonna be a hard time it's gonna be a hard time for you too um again ask if they can you can call somebody you get somebody over here to help them out um and again if i i've seen this before i've seen children sitting on the stairway while you're talking to you know the spouse and the the young children just don't understand what's going on you know they need to be part of this as well that's the still going to be a bad memory for them your cpr skills can deteriorate over time hopefully they don't hopefully as an emt you unfortunately will have a mastery of your skills of cpr so practice using a mannequin as often as you can again cpr self instruction through a video or a computer based computer based module with hands-on practice every two years you should renew your cpr in most states you have to renew your cpr to maintain your emt license so as a as a paramedic i have to maintain my cpr as well as my advanced cardiac life support skills you have to maintain that don't let it elapse think about cpr in the public you're a patient advocate hopefully uh some of you will start teaching cpr classes and letting people know that it's really important to know cpr and how to use an aed a lot of people think that if they know how to use an aed they don't need to know how to do cpr no it's the two together that make it because not every aed is going to shock a person i don't know if you know that or not but aeds only shock certain bad rhythms it they're not like jumper cables on your car restarting a dead battery it has to recognize a bad cardiac rhythm to let you shock it back to good if the aed is placed on someone and it doesn't detect that rhythm then you need to start cpr and the machine the aed will tell you no shock advice begin cpr so the machine's not broken the person really is broken and we're not able to defibrillate them so the only thing that's going to be available for them is cpr so if brain damage is very likely in a brain that does not receive oxygen for how many minutes yep four to six minutes four to six minutes without oxygen irreversible brain damage is likely which of the following sequences of events describe the american heart association chain of survival early access post arrest care that doesn't work b early advanced care that doesn't work so early access yep early cpr early defibrillation early advanced care c sounds right d early access early riser what the heck does that mean so it is obviously c i don't know what early riser is but that was a cute answer so again early access early cpr early defibrillation early advanced care and integrated post arrest care and the last thing is recovery for cpr to be affected the person must be on a firm surface lying in the blank position fowler prone supine recovery if you don't remember followers sitting up prone is on your belly supine is on your back recovery's on your side we obviously have to have them on their back the supine position in order for you to do good cpr if they're on their stomach we need to roll them over if they're sitting in a chair we need to pull them out of the chair and put them on the floor if they're in bed pull them out put them on the floor that's the only way you're going to do high quality cpr if you think about doing cpr in a bed when you push down on the chest the bed is going to be spongy so you're not going to be able to squish that heart between the sternum and the backbone it's just going to kind of bounce and you're doing horrible cpr you're not doing anything you got to get them on the floor pulse check should take one at least one second but no more than five at least 10 seconds or at least five seconds but no more than ten that's a good question that's a really good question pulse check how long should we take to check for a pulse [Applause] less should take at least five seconds but no more than 10 seconds the reason why it should take at least five seconds is because we're checking and seeing if they have a slow pulse if you only check for one second and you're not going to feel a pulse and if it's 5 seconds no more than 10 seconds even if it's slow you should feel it that's the rationale artificial ventilation may result in the stomach becoming filled with air a condition called gastric distension vomitus abdominal thrust maneuver or acute abdomen what's the term for air in their stomach yup gastric inflation again you're bagging too hard you're bagging too fast and you're forcing air past the epiglottis down into their stomach and you'll note that their stomach gets bigger and bigger during your whole cpr event it's eventually what's gonna come out is what's in the stomach what is it always right beer and pizza the blank is a circumferential chest compression device composed of a constricting band and backboard mechanical piston device that doesn't sound right load distributing band impedance threshold device that's the device that goes on the airway or cardiopulmonary pulmonary resuscitation well that's cpr so it's got to be b load uh distributing band again the device that goes around your your chest like a vest that's what this is it kind of squeezes your whole chest and not just push down on your heart it really kind of does a better job than the piston device but the the best device usually costs about fifty thousand dollars where the piston device is usually about twenty thousand dollars it's an expensive piece of equipment and not every ambulance will have either one depending on where you work that's just a lot of money which of the following scenarios would warrant an interruption of cpr a hysterical family member trying to gain access to the unconscious patient a vehicle honking its horn anxious to pass by the scene of a blocked road a small set of steps leading to the exit of the building on the way to the ambulance being tired from trying to resuscitate a patient which would warrant an interruption in cpr so if you're doing cpr and you're moving the person from the house to your ambulance you cannot do good cpr on stairways so again you might have to take a short break no more than 10 seconds to move them hysterical family member does not warrant a break in cpr hopefully there's somebody else there that can take care of that family member the honking horn let the cops take care of that stuff that's not our job again cpr is what we're doing for this person being out of breath does not mean physically incapable of doing cpr if you're out of breath you can still do cpr now when you get to the point where you physically cannot do cpr that's when you have to stop if it's just you so once you start cpr in the field you must continue until one of the following events occur the patient stops breathing and has no pulse no that's what we're doing is cpr for that the patient is transferred to another person who's trained bls to als trained personnel or to another emergency medical opera responder see you're out of gas in the ambulance rd a police officer resumes responsibility for the patient gives direction to discontinue cpr we don't take our orders from the police uh i even if your ambulance runs out of gas you're still going to be doing cpr and a or doing cpr because they're not breathing and have no pulse so it's got to be b transferring that's part of that stop acronym uh you know the the s-t-o-p so we're gonna the t and stop transfer and hopefully your ambulance doesn't run out of gas now if a doctor tells you to stop then that's when we can stop but not a cop sorry if i offend the police officers out there but i used to be a cop also so i use the term cop number nine instead of the abdominal thrust maneuver use blank for women in advanced stages of pregnancy and patients who are obese remember you can't get your arms around them uh to their belly a if they're obese or b we don't want to be pushing on that baby so what do we do chest rust the cellic maneuver basic life support or dr nr orders well the bottom two really don't apply so is it the cellic maneuver or chest rust yep chest rust we can't be down on the baby or if we can't reach around and grab them you know sometimes our ems providers are on the smaller side and obviously our patients are getting bigger uh so it makes it very difficult so you sh you might be able to do chest rust that's the thing that we're thinking about and the last question so in infants who have signs and symptoms of an airway infection you should not waste time trying to dislodge a foreign body you should intervene only if signs of blank develop such as a weak ineffective cough cyanosis strider absent air moving or a decreasing level of consciousness you should intervene only if signs of sids occur child abuse bronchitis or severe airway obstruction yeah the airway obstruction a mild one they might be able to keep coughing and get that object out in a severe obstruction we're not going to be able to get that out they're not going to be able to breathe we do cpr in sids patients again sids is that sudden infant death syndrome um they've stopped breathing for some reason and and we're doing cpr child abuse they might be uh you might encounter that in your career but again that's not going to make the airway obstruction bronchitis is an inflammation of their lungs but it's it's a disease process it's not going to block and not be a foreign body blocking the airway and again a severe airway obstruction that's really what we're going to be doing okay so that's the end of bls you also have to obtain your bls certification as part of this course make sure you upload your bls card once you have it so that we can have that on file for you as well