Basic Life Support

6 actions of cardiac arrest chain of survival

Recognition and activation, high-quality CPR, defibrillation, advanced life support, integrated post-cardiac arrest care, recovery and survivorship

Duty to act

When a patient experiences a life-threatening emergency (be familiar with your facility and agency protocols)

Good Samaritan laws

All states have these laws in place to protect people who voluntarily give care in good faith

Recognition and activation

Immediate recognition of cardiac arrest and activation of advanced help, such as EMS (9-1-1) or the rapid response or resuscitation team quickly provides the patient with access to necessary personnel, equipment, and intervention

High-quality CPR

Initiating compression and ventilations immediately after recognizing cardiac arrest

Defibrillation

May restore an effective heart rhythm, which increases the patient’s chance for survival

AED

Automated external defibrillator; a portable device that automatically analyzes the patient’s heart rhythm and provide defibrillation (an electrical shock that may help the heart reestablish a perfusing rhythm)

Perfusing rhythm

The heart pumps enough blood to produce a detectable pulse

Advanced life support

Provided by EMS professionals at the scene and en route to the hospital, and continues through specialty interventions provided in the hospital

Recovery and survivorship

Physical and psychosocial therapy helps the patient, caregivers, and co-survivors return to a productive life

Continuous quality improvement

Addressing human factors, team dynamics, and system-level performance factors are key to improving safety and outcomes

Components of continuous quality improvement

Individual and team training, event evaluation, review of data by a multidisciplinary team, and continual reevaluation of data to monitor area of improvement

5 critical components of high-quality CPR

Providing compressions at the proper rate, providing compressions at the proper depth, allowing full chest recoil, avoiding excessive ventilations, and minimizing interruptions to chest compressions

ROSC

Return of spontaneous circulation

How to increase the likelihood of ROSC

Provide the highest quality of CPR at all times to give the patient the best chance for neurologically intact survival following cardiac arrest

Methods of evaluating CPR quality

Visual observation, feedback devices, chest compression fraction, capnography, post-resuscitation and debriefing

Visual observation during CPR

Allows for in-the-moment adjustments to compression and ventilation technique based on feedback from the team leader or another team member

Feedback devices used during CPR

Designed to act as virtual coaches to guide responders to adjust their technique to perform effective, high-quality CPR by using technology to gather data, such as rate of compressions and ventilations, depth of compressions, and chest recoil

Chest compressions fraction (CCF)

An important indication of CPR quality and represents the % of time during resuscitation effort that is spent performing compressions

CCF format

CCF = time delivering compressions/total duration of resuscitation event

What does a CCF of 80% mean?

80% of the time, the team is circulating blood through the patient by providing compressions

Capnography

Measure the end-tidal carbon dioxide level (ETCO2) in a noninvasive way of obtaining an objective measure of compression quality with every ventilation

Post-resuscitation reflection and debriefing

Allows the team to evaluate any necessary changes to positively affect the outcome of future resuscitation events

Closed-loop communication

Structured form of communication to ensure clarity, accuracy, and confirmation in information exchange

Sender

Person initiating communication who conveys the message to a specific receiver by looking directly at them and calling them by name

Message

The context of communication which must be expressed clearly so that everyone involved knows exactly what is being conveyed

Receiver

The person to whom the message is directed and will acknowledge by repeating the message back to the sender

Confirmation

By the receiver that the message is received and understood by repeating the message back to the sender

Closing the loop of communication

The sender waits for feedback from the receiver that the action was completed to ensure that the message sent is the message received

Critical thinking

Identify new information, logically adapting to the information to determine best next actions, and anticipating effects on the patient

Situational awareness

Constantly evaluation your environment and adjusting based on information from multiple sources, usually in a fast-paced coomplex environment

Problem-solving

Using readily available resources to find solutions to challenging situations or issues that arise

Team leader

Oversees entire resuscitation effort and ensures that everyone works as a team to help promote the est possible outcome for the patient

Team leader responsibilities

Assigns and understands team roles

Prioritizes, directs, and acts decisively

Monitor and coaches performance

Re-evaluates and summarizes progress

Leads a reflection and debriefing session

Consent

Attempt to obtain this from the patient or from the patient’s parent or guardian if they are a minor prior to initiating care

Steps to obtaining consent

Identify ourself, explain what you plan to do and what you observe, ask for permission from the parent or guardian to provide care, honor their wish if they refuse care, call 9-1-1 if emergency care is still needed

Implied consent

If a patient is unresponsive, has an altered mental state, is mentally impaired, or is unable to give consent verbally or nonverbally

Infant

<1 year old (excluding newborns)

Child

From 1 year old to the onset of puberty (~12 years old)

Adult

Past the onset of puberty through adulthood, including adolescents

Assess, recognize, and care

A systematic, continuous approach for rapid assessment, accurate recognition, and immediate care (repeat steps until the patient is stabilized or transferred to a higher level of care)

Standard precautions

Safety measures to prevent disease transmission based on the assumption that al bodily fluids may be infectious

Visual survey

Ensure the environment is safe for you, your team, the patient, and anyone else

What to check for visually during a rapid assessment

Does the patient ok sick or unresponsive?

Does their skin appear pale, mottled, or cyanotic?

Do they appear to be breathing?

Is there life-threatening bleeding?

Life-threatening bleeding

Control the hemorrhage with any available resource (e.g. direct pressure, use of a tourniquet, hemostatic dressing), then activate EMS, rapid response, or resuscitation teams, and call for an AED

Check for responsiveness

Obtain consent from the patient, then provide care

Assessment of an unresponsive patient

Shout “Are you okay?”

Tap their shoulders (adult or child) or tap their foot (infant)

If you are alone, call for help and an AED

Assessment of an unresponsive patient with another responder

The first responder focuses on checking for a pulse and breathing simultaneously

The other responders call for help and retrieve the AED and BVM (bag-valve mask) or ambu-bag

Open the airway while simultaneously checking for breathing and a pulse

Make sure the patient is face-up

Open the airway using the head-tilt, chin-lift technique, or a modified jaw-thrust maneuver if a a head, neck, or spinal injury is suspected

Simultaneously check for breathing and a pulse

Start CPR immediately if a pulse is not definitely felt

How do you check the pulse for an adult or child?

Palpate the carotid artery by placing 2 fingers in the groove of the neck (be careful not to reach across the neck and obstruct the airway)

How do you check the pulse of an infant?

Fully expose the arm to palpate the brachial artery by placing 2 fingers on the inside of the upper arm

When to use the modified jaw-thrust maneuver

Use this method to open the airway if you suspect a head, neck, or spinal injury

Steps for the modified jaw-thrust maneuver

Position yourself above the patient’s head

Position one and on each side of the patient’s head with your thumbs near the corners of the mouth and pointed towards the chin

Use your elbows for support

Slide your fingers under the angle of the jawbone without moving their head or neck

Open the airway by thrusting the jawbone without moving up, without moving the head or neck to lift the jaw

Recognizing cardiac arrest

The patient is not breathing (or only gasping) and their pulse is absent

Proper care

Cannot be provided without effective assessment and accurate recognition of a patient’s condition

Causes of cardiac arrest

The heart stops beating, which stops blood flow to the brain and other vital organs (may be an effect of myocardial infarction aka heart attack)

Agonal breaths

An unresponsive person appears to be gasping for air or is making irregular gasping or snoring noises, which can occur after the heart has stopped breathing

Compression cycle for adults

30:2 (30 chest compressions, followed by 2 ventilations)

Compression rate for adults, children, and infants

100 to 120 compressions per minute

Compression depth for adults

At least 2 inches, but no more than 2.4 inches

What improves circulation generated by CPR?

Allowing full chest recoil after each compression, having equal compression and recoil times, and minimizing interruptions to <10 seconds

Patient placement for chest compressions

Ensure the patient is lying on their back on a firm, flat surface

Responder position when giving chest compressions

Stand or kneel at the side of the patient’s chest

Hand positions for giving chest compressions

Place the heel of one hand in the center of the patient’s chest on the lower half of their sternum

Place your other hand on top of the first hand

Interlace your fingers and make sure they are up off the chest

Lock your elbows, then align your shoulders directly over your hands

How many ventilations should you deliver?

Deliver 2 ventilations that last ~1 second each and make the chest begin to rise

Allow the air to exit before delivering the next ventilation

Do not overinflate/hyperinflate the lungs

If the chest does not rise after each ventilation:

Reopen the airway, make a seal, and try a second ventilation

Unsuccessful second ventilation

Assume the patient has an obstruction, return to chest compressions and check the mouth for any objects that may have been dislodged before giving the next ventilation

CPR breathing barrier

Protects you from coming into contact with the patient’s blood, vomit, or saliva and protects from breathing in their exhaled air

Pocket mask ventilations

Recommended during single-responder CPR to protect the responder and omit prolonged interruptions in chest compressions that may come from using a bag valve mask (BVM)

Bag valve (BVM) device

Breathing device that is most effectively used when there are 2 responders

Supplemental oxygen to facilitate ventilations

Attach to the BVM device as soon as appropriate and when enough resources are available

Basic airways

Oropharyngeal and nasopharyngeal airways

Advanced airways

Deliver one ventilation every 6 seconds while another responder delivers continuous chest compressions at a rate of 100 to 120 per minute without pausing for ventilations

Continue CPR until

You see ROSC

Other responders arrive to relieve you

You are too exhausted to continue

The situation becomes unsafe

Multiple responder CPR roles

One responder performs chest compressions while one or two others manage the airway and deliver ventilations

How should you switch roles during multiple responder CPR?

Switch roles ~2 minutes to maintain CPR and minimize responder fatigue (should only take ~10 seconds to switch)

Switching the compressor during multiple responder CPR

Call for a role change by saying “switch” in place of the number 1 in the compression cycle

Where to avoid placing AED pads

Breast tissue, implanted or external medical devices, jewelry, medication patches

After the AED delivers a shock or if no shock is needed

Immediately begin CPR for ~2 minutes until the AED prompts that it is reanalyzing, the patient shows signs of ROSC, the team leader or other responders instruct you to stop

How to start CPR when using an AED with multiple responders

The first responder performs the rapid assessment and initiates CPR 30:2, starting with chest compressions

High-quality CPR for pregnant patients

Same compressions, ventilations, and AED use

Prioritize early transportation over care at the scene

Call for additional resources early (activate maternal and neonatal resuscitation teams)

Use left uterine displacement (LUD) if you have the resources to do so

Left uterine displacement (LUD)

Process of pulling or pushing the noticeably pregnant abdomen (usually ~20 weeks) to the left side to relieve the pressure on the large blood vessels that run down the abdomen, which improves blood flow to the heart — maintain throughout and maintain resuscitation

LUD on the patient’s left side

Reach across the left side, put both hands on the right side of the uterus, and pull it to the left and up

LUD on the patient’s right

From the right side, place both hands on the right side of the uterus, then push it to the left and up

How to open the airway

Place one hand on the forehead and 2 or 3 fingers of the other hand on the bony underside of the chin, then tilt the head

Opening the airway for adults

Past-neutral position

Opening the airway for children (age 1 through the onset of puberty)

Slightly-past neutral position

Opening the airway for infants

Neutral position

Delivering ventilations to adults in respiratory arrest

1 ventilation every 6 seconds

Delivering ventilations to children (age 1 through onset of puberty) and infants (birth to age 1) in respiratory arrest

1 ventilation every 2-3 seconds if pulse is >60 BPM (check pulse after 2 minutes)

What to avoid when opening the airway

Hyperextension of the neck or pressing on the soft tissue under the chin or neck

Sniffing position

The appropriate open airway position (may be helpful to place a small towel underneath the shoulders of a small child or infant)

Cardiac arrest in children and infants

More likely to be caused by a respiratory event, rather than a primary cardiac event

Chest compression depth for children

~2 inches or 1/3 the depth of the chest

Chest compression depth for infants

~1.5 inches or 1/3the depth of the chest

One-handed technique

Can be used to deliver chest compressions to small children and infants

One-handed technique positioning

Place the heel of one hand in the center of the chest, on the lower half of the sternum just below the nipple line (position your shoulder directly over your hand to compress up and down)

Encircling thumbs technique

Can be used to deliver chest compressions to infants

Encircling thumbs technique positioning

Place both thumbs side-by-side on the center of the infant’s chest, just below the nipple line

Use the other fingers to encircle the chest toward the back, providing support

Checking the pulse of a child as a single responder

Palpate the carotid artery for at least 5 seconds, but no more than 10 seconds