BLS Resuscitation Notes

Emergency Care and Transportation of the Sick and Injured - BLS Resuscitation

Introduction

• Basic Life Support (BLS) principles were introduced in 1960.
• Techniques are regularly reviewed and revised.
• The most recent review was conducted in 2020 by the International Liaison Committee on Resuscitation (ILCOR).

Elements of BLS

• BLS is a noninvasive emergency life-saving care.
• Used to treat:
  • Airway obstruction
  • Respiratory arrest
  • Cardiac arrest
• Focus on the ABCs:
  • Airway (obstruction)
  • Breathing (respiratory arrest)
  • Circulation (cardiac arrest or severe bleeding)
• Seconds count!
• Permanent brain damage is possible if the brain is without oxygen for 4 to 6 minutes.

Cardiopulmonary Resuscitation (CPR)

• CPR reestablishes circulation and artificial ventilation in a patient who is not breathing and has no pulse.
• CPR Steps:
  • Restore circulation (chest compressions).
  • Open the airway.
  • Restore breathing (rescue breathing).

BLS vs. ALS

• BLS differs from Advanced Life Support (ALS).
• ALS Involves:
  • Cardiac monitoring
  • Intravenous fluids and medications
  • Advanced airway adjuncts

AHA Chain of Survival

• Recognition and activation of the emergency response system
• Immediate, high-quality CPR
• Rapid defibrillation
• Basic and advanced emergency medical services
• ALS and post-arrest care
• Recovery

Assessing the Need for BLS

• Survey the scene.
• Complete primary assessment ASAP.
• Evaluate ABCs.
• Determine unresponsiveness (should take less than 10 seconds).
• BLS principles are the same for all ages
• Cardiac arrest in adults usually occurs before respiratory arrest, but in infants and children, the reverse is generally true.

Automated External Defibrillation (AED)

• A vital link in the chain of survival.
• Apply to cardiac arrest patients ASAP.
• If you witness cardiac arrest, begin CPR and apply the AED as soon as it is available.
• Children:
  • Apply after the first five cycles of CPR.
  • Use pediatric-sized pads and a dose-attenuating system.
  • If neither is available, use an AED with adult-sized pads with anterior-posterior placement.
• Special Situations:
  • Pacemakers and implanted defibrillators
  • Wet patients
  • Transdermal medication patches

Positioning the Patient

• For CPR to be effective, the patient must be supine on a firm, flat surface.
• Ensure enough space for two rescuers to perform CPR.
• Log roll the patient onto a long backboard.

Check for Breathing and Pulse

• Quickly check for breathing and a pulse.
• Visualize the chest for signs of breathing.
• Palpate for a carotid pulse.
• Provide external chest compressions
• Apply rhythmic pressure and relaxation to the lower half of the sternum.
• Compressions squeeze the heart, acting as a pump to circulate blood.
• Avoid leaning on the chest in between compressions.
• Allow the chest to completely recoil between compressions.
• Proper hand positioning is crucial.
• Injuries can be minimized by proper technique and hand placement.
• Compression and relaxation should be rhythmic and of equal duration (1:1 ratio).

Opening the Airway and Providing Artificial Ventilation

• Head tilt-chin lift maneuver
• Jaw-thrust maneuver
• If a patient is adequately breathing and there are no signs of injury to the head, spine, hip, or pelvis, place the patient in the recovery position to maintain a clear airway and allow vomitus to drain from the mouth.
• The combination of a lack of oxygen and too much carbon dioxide in the blood is lethal.
• If a patient is not breathing, ventilations can be given by one or two EMS providers, using a barrier device.
• Use a bag-mask device for ventilations.
• For a patient with a stoma, place a bag-mask device or pocket mask device directly over the stoma.
• Artificial ventilation may result in gastric distention; have a suction unit available in case the patient vomits.

CPR Techniques

• One-Rescuer Adult CPR
  • A single rescuer gives both chest compressions and artificial ventilations.
  • The ratio of compressions to ventilations is 30:2.
• Two-Rescuer Adult CPR
  • Always preferable to one-rescuer CPR.
  • Less tiring.
  • Facilitates effective chest compressions.
  • Switching rescuers during CPR is critical to maintaining high-quality compressions; it is recommended to switch positions every 2 minutes.

Devices and Techniques to Assist Circulation

• Active compression-decompression CPR
  • Involves compressing the chest and then actively pulling it back up to its neutral position.
• Impedance threshold device (ITD)
  • Limits air entering lungs during recoil phase between chest compressions.
• Mechanical piston device
  • Allows the rescuer to configure the depth and rate of compression.
• Load-distributing band CPR or vest CPR
  • A circumferential chest compression device composed of a constricting band and backboard.
  • Manual chest compressions remain the standard of care.

Infant and Child CPR

• Cardiac arrest in infants and children follows respiratory arrest.
• Airway and breathing are the focus of pediatric BLS.
• Causes of child respiratory problems:
  • Injury
  • Infections
  • Foreign body
  • Submersion
  • Electrocution
  • Poisoning/overdose
  • SIDS
• Determine unresponsiveness; gently tap on the shoulder and speak loudly.
• Check for breathing and a pulse:
  • Assessment occurs simultaneously and should take no longer than 10 seconds.
• Foreign body obstruction in children is common.
• Place an unresponsive, breathing child in the recovery position.
• The techniques for opening the airway are modified for pediatric patients; place a wedge under the upper chest and shoulders when supine.
• Provide rescue breathing:
  • Not breathing and has a pulse: 1 breath every 2 to 3 seconds.
  • Not breathing and no pulse: 2 breaths after every 30 compressions.

Interrupting CPR

• CPR is a crucial, life-saving procedure.
• If no ALS is available at the scene:
  • Provide transport per local protocols.
  • Consider requesting ALS rendezvous en route to the hospital.
• Chest compression fraction:
  • The total percentage of time during a resuscitation attempt in which chest compressions are being performed; should be at least 80% (the higher, the better).

When Not to Start CPR

• If the scene is not safe.
• If the patient has obvious signs of death:
  • Rigor mortis (stiffening of the body)
  • Dependent lividity (livor mortis)
  • Putrefaction or decomposition of the body
  • Evidence of nonsurvivable injury
• If the patient and physician have previously agreed on do not resuscitate (DNR) orders; when in doubt, begin CPR.

When to Stop CPR

• Once you begin CPR, continue until:
  • S Patient Starts breathing and has a pulse.
  • T Patient is Transferred to another provider of equal or higher-level training.
  • O You are Out of strength.
  • P Physician directs to discontinue.

Foreign Body Airway Obstruction in Adults

• Airway obstruction may be caused by:
  • Relaxation of throat muscles
  • Vomited or regurgitated stomach contents
  • Blood
  • Damaged tissue
  • Dentures
  • Foreign bodies
• In adults, usually occurs during a meal; in children, usually occurs during a meal or at play.
• A patient with mild airway obstruction is able to exchange air but with signs of respiratory distress.
• Sudden, severe obstruction is usually easy to recognize in responsive patients.
• In unresponsive patients, suspect obstruction if maneuvers to open the airway and ventilate are ineffective.
• The abdominal-thrust maneuver (Heimlich) is recommended in responsive adults and children older than 1 year.
• Instead of the abdominal-thrust maneuver, use chest thrusts for the following responsive patients:
  • Women in advanced stages of pregnancy
  • Obese patients
• Unresponsive patients:
  • Determine unresponsiveness.
  • Check for breathing and a pulse
  • If a pulse is present and breathing is absent, attempt ventilation; if two attempts do not produce visible chest rise, perform 30 compressions, open the airway, and look in the mouth; attempt to carefully remove any visible object.

Foreign Body Airway Obstruction in Infants and Children

• Common problem
• If there are signs and symptoms of airway obstruction, do not waste time trying to dislodge a foreign body.
• On responsive, standing or sitting child, perform Heimlich maneuver
• On an unresponsive child older than 1 year, manage in the same manner as an adult.
• Responsive infants
  • Do not use abdominal thrusts.
  • Perform back slaps and chest thrusts (compressions).
• In unresponsive infants, begin CPR, beginning with chest compressions. Do not check for a pulse before starting compressions. Open the airway and look in the mouth; remove the object if seen; resume chest compressions if no object is seen.

Special Resuscitation Circumstances

• Opioid overdose
  • Standard resuscitation measures take priority over naloxone administration.
• Cardiac arrest in pregnancy
  • Priorities are to provide high-quality CPR and relieve pressure off the aorta and vena cava.

Grief Support for Family Members and Loved Ones

• Family members may experience a psychologic crisis that turns into a medical crisis.
• Keep the family informed throughout the resuscitation process.
• After resuscitation has stopped, helpful measures include:
  • Take the family to a quiet, private place.
  • Use clear language and speak in a warm, sensitive, and caring manner.
  • Exhibit calm, reassuring authority.
  • Use the patient’s name.
  • Use eye contact and appropriate touch.
  • Expect emotion.
  • Be supportive but do not hover.
  • Ask if a friend or family member can be called.
  • Ensure that children are not ignored.

Education and Training for the EMT

• CPR skills can deteriorate over time.
• Practice often using manikin-based training.
• CPR self-instruction through video and/or computer-based modules with hands-on practice.

Education and Training for the Public

• You are a patient advocate. You must do your part to facilitate the training of laypeople in the critical skills of CPR and AED operation.

Review

• Brain damage is very likely in a brain that does not receive oxygen for 6–10 minutes.
• The AHA chain of survival: early access, early CPR, early defibrillation, early advanced care, integrated post-arrest care, and recovery.
• For CPR to be effective, the patient must be on a firm surface, lying in the supine position.
• The pulse check should take at least 5 seconds but no more than 10 seconds.
• Artificial ventilation may result in the stomach becoming filled with air, a condition called gastric distention.
• The load-distributing band is a circumferential chest compression device composed of a constricting band and backboard.
• A scenario that would warrant an interruption in CPR procedures: a small set of steps leading to the exit of the building, on the way to the ambulance.
• Once you begin CPR in the field, you must continue until the patient is transferred to another person who is trained in BLS, to ALS- trained personnel, or to another emergency medical responder.
• Instead of the abdominal-thrust maneuver, use chest thrusts for women in advanced stages of pregnancy and patients who are obese.
• 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 severe airway obstruction develop, such as a weak, ineffective cough, cyanosis, stridor, absent air movement, or a decreasing level of consciousness.