BLS Study Guide
Questions
What is BLS? cardiac or resp arrest
AED → rhythms effective or ineffective
Why blanket under right hip of pregnant women
What should responder do while AED is charging?
continue compressions
Chest compression fraction definition
the percent of time doing compressions during an arrest
2 most common forms of PPE
Gloves and goggles
Introduction to Basic Life Support
Legal Issues
Consent: Consent is the legal permission that pt gives to receive care
Responsive Patient: it is required that you get consent from the pt before performing assessments or treatment
Unresponsive Patients: is cases where the pt is unresponsive the law assumes that the pt would grant consent if they were able to do so (implied consent)
Abandonment: Once you have initiated treatment for a pt, you are legally required to continue.
Advanced Directives: Documented instructions for a competent person that outlines the individuals wishes concerning healthcare discissions.
Basic Life support Skills
Doffing Gloves
first, pinch the wrist of the glove with the other gloved hand, pull glove off, and rest in gloved hand without touching outside of either glove with now ungloved hand, then tuck now ungloved fingers under the wrist of the other glove without touching the outside and pull off in doing so encapsulating the first glove. Ensure gloves are inside out
Primary Assessment
Level of Responsiveness: determine the pts LOR by gently tapping the pt on the shoulder and asking “Are you okay?”
Open the Airway
To open and assess an unresponsive pts airway, perform a head-tilt/chin life:
1. place two fingers under the pts jaw
2. place the palm of your other hand on the pts forehead
3. tilt the pts head back while lifting the chin
this motion will reposition the tongue so that it does not block the airway
When assessing an infant, avoid hyperextending the neck.
If the pt has a suspected spinal injury, perform a jaw thrust:
1. kneel or stand behind the patients head
2. place place both palms on the pts cheekbones
3. place two fingers of each hand under the pts mandible and pull forward
If the jaw thrust is unsuccessful, do a head-tilt chin lift, keeping the neck in line with the body
Check Breathing and Circulation
Simultaneously check the pts breathing and circulation (carotid pulse) for no longer than 10 seconds. If no pulse is detected after a max of 10 secs, initiate CPR/AED
Agonal Respirations: an inadequate and irregular pattern of breathing sometimes associated with cardiac arrest. If pt indicates agonal resps, they are not breathing normally
Checking pulse:
Responsive adult or child: place two or three fingers over the radial artery
Unresponsive adult or child: place two or three fingers over one of the carotid arteries
Infant: place one or two fingers over the brachial artery
CPR
A pt who is unresponsive and does not have a pulse requires CPR
Chest compressions
Adult:
Hand pos: Two hands on sternum
Compression depth: at least 5cm about 2 in
One responder cycle: 30 compressions, 2 ventilations
Two responder cycle: 30 compressions, 2 ventilations
Compression rate: 100-120 per min (30 compressions in 15-18 secs)
Child:
Hand pos: One or two hands on sternum
Compression depth: 1/3 the depth of the chest
One responder cycle: 30 compressions, 2 ventilations
Two responder cycle: 15 compressions, 2 ventilations
Compression rate: 100-120 per min (30 compressions in 15-18 secs)
Infant:
Hand pos: Two fingers on sternum (just below nipple line) OR encircling method
Compression depth: 1/3 the depth of the chest
One responder cycle: 30 compressions, 2 ventilations
Two responder cycle: 15 compressions, 2 ventilations
Compression rate: 100-120 per min (30 compressions in 15-18 secs)
Neonate:
Hand pos: Two fingers on sternum (just below nipple line) OR encircling method
Compression depth: 1/3 the depth of the chest
One responder cycle: 3 compressions, 1 ventilation
Two responder cycle: 3 compressions, 1 ventilation
Compression rate: 100-120 per min (30 compressions in 15-18 secs)
For two responder CPR: after aprox. 2 mins (~5 cycles) of continuous CPR, responders should switch to avoid fatigue and maintain high-quality CPR
Minimize CPR interruptions:
Chest compression fraction is the measurement of the amount of time that compressions are being performed. A chest compression fraction time of around 80% is the goal, with a minimum of 60%.
Resus. Masks
A resus mask (or pocket mask) is used for direct ventilation. It also acts as PPE providing a barrier between you and the pt during CPR
BVM
a BVM is used for a pt in respiratory arrest or a pt whose RR is too low or too high. A BVM is best used by two responders. To properly use a BVM, you must attach it to an oxygen reservoir bag. If you are using a BVM without a partner you must maintain the mask seal with one hand, monitor the airway, and simultaneously provide ventilations with the other hand.
Children and infants:
Some BVMs are designed specifically for children and infants, these BVM's also include a valve that prevents over inflation of the lungs.
Defibrillators
The AED is the most common defibrillator, but there are many others that vary slightly in use. It is important that you know and follow the manufacturer’s instructions for the proper use and maintenance of your particular defibrillator. Use a defibrillator in combo with CPR for pts in cardiac arrest. If two responders are present, one should begin CPR while the other applies the pads to the pt. Activate the defibrillator immediately to allow the device to begin analyzing the pts rhythm.
1. expose and prepare the pts chest
2. Attach the pads to the pts chest as directed by the instructions
typically, one pad is placed on the upper right side of the chest and the other is placed on the lower left side with 2.5cm or 1 in of space between them
3. pause CPR to allow the machine to analyze. Do not touch the pt or the defibrillator during this time. The defibrillator with notify you when the analysis is complete. Follow the defibs prompts.
4. Continue CPR while the defibrillator charges
5. Resume CPR, follow the defibs prompts and reanalyze after 5 CPR cycles.
If shock advised, shock and then later advises no shock, the pts condition has changed. Quickly reassess the pts circ before proceeding
*if the pt is pregnant, elevate the right hip (using a blanket or cushion etc.) to help blood flow return to the heart, only if doing so does not disrupt CPR.
Special considerations:
do not defib neonates (0-28 days)
do not defib in water
do not defib in the presence of flammable materials
do not defib while in motion or in a moving vehicle.
Airway Obstruction
there are two types of airway obstructions
1. anatomical airway blockage
this occurs when the airway is blocked by an anatomical structure (eg. tongue, swollen tissue etc.)
2. foreign-body airway obstruction (FBAO)
occurs when the airway is blocked by a foreign object (eg. food) or by fluids (eg. vomit). This may be referred to as a mechanical obstruction.
An airway obstruction can be either partial or complete
partial
the pt can breath but has difficulty (e.g. wheezing )
Have the pt cough forcefully. if possible have the sit down and lean forward
partials can quickly escalate to complete choking; monitor the pt closely
Complete airway obstruction
the pt cannot speak, breath, or cough effectively.
the pt may be able to cough weekly or make high pitched noises.
immediate interventions is required
interventions for both responsive and unresponsible patients with complete airway obstructions are primarily effective for FBAO, but these interventions should be attempted even if you are unsure whether the obstruction is anatomical or mechanical (FBAO)\
Responsive adult or child
alternate between at least two of the following three methos for clearing an FBAO in a responsive adult or child: back blows, abd thrusts, and chest thrusts. choose the method most suitable for the pt. Regardless of the combination of methods you choose, continue interventions until one of the following occurs:
the FB is dislodged
the pt begins to breath or cough
the pt becomes unresponsive
if the pt becomes unresponsive and collapses, begin treatment for an unresponsive pt.
if the pt is in a wheelchair, lock the wheels before providing care.
Back Blows
1. assume a stable stance behind pt
wrap one arm around the pts chest and bend the pt forward at the waist until the upper airway is at least parallel to the ground
2. with the heel of your other hand, deliver 5 firm blows between the shoulder blades, checking after each blow to see if the obstruction cleared.
Abd. Thrusts
1. Assume stable stance behind the patient
2. make a fist and place if thumb-side-in, just above the naval and well below the lover tip of the sternum (breastbone)
3. Grasp your fist with your other hand and give up to 5 quick upward thrusts into the abd, checking after each thrust to see if the obstruction cleared
abd thrusts are a good default choice for most pts, but they are not suitable for pregnant women and may be difficult with bariatric (obese) pts. In these cases, chest thrusts are recommended.
Chest Thrusts
1.Assume stable stance behind the patient
2. make a fist and place if thumb-side-in, against the sternum
3. Grasp your fist with your other hand and give up to 5 quick thrusts pulling directly back towards you with each one and checking after each thrust to see if the object has been dislodged.
Unresponsive Child or Adult
1. perform sets of 30 chest compressions as in the CPR Protocol.
2. after performing each set of 30 chest compressions, look inside the pts mouth
if you see an object, carefully remove it using a finger sweep: Grasp the tongue and lover jaw and lift, then sweep the object out using your finger
3. after looking in the mouth, or after removing the object, open the airway and attempt to ventilate
if your ventilation goes in, give a second ventilation
if your first ventilation does not go in, reposition the head and attempt a second ventilation. If it does not go in, resume CPR sequence starting with 30 chest compressions. Repeat this sequence until the airway clears.
4. If your ventilations cause the chest to rise, the obstruction is clear. Reassess and provide care according to what you find.
*Tilting the pts head back farther is only necessary on your initial unsuccessful ventilation: on consecutive cycles, simply attempt one ventilation and then resume compressions.
Primary Assessment (ABC) → Resp Absent pulse present → I attempt 2 ventilations → Vent successful = Resp arrest, Vent I unsuccessful = Airway obstruction →Attempt 1 vent → Vent I successful → give 2nd vent → Reassess pts ABCs → Pulse I absent = Cardiac arrest, Resp absent = resp arrest.
if respirations present → unresponsive consider causes of unresponsiveness.
L> Resp absent pulse absent → Cardiac arrest
Responsive Infant
support the head and neck of the infant during interventions. Remember to check after each back blow and chest compression to see if the object has been dislodged.
Unresponsive Infant
1. Perform 30 chest compresions as in the CPR protocol
2. Visually inspect the mouth
open the infants mouth by placing your thumb on the lower teeth and gently opening the mouth
look for an object. if you can see it, carefully pick it out with your thumb and litte finger
3. open the airway and attempt to ventilate
if the ventilation goes in, give a second
if the infants chest does not rise after the first vent, reposition the head to adjust the airway and attempt to give another ventilation. Repeat the set of compressions, then look inside the infants mouth for a foreign object prior to attempting ventilations again.
4. Repeat the sequence until the airway is clear or you transfer care of the pt
*Tilting the infants head back further is only necessary on your initial vent attempt
Obstructed Airway self-rescue
if you are alone and you are choking, dial EMS/911 and leave the phone off the hook. This will tell the dispatcher where to send help. if there are people nearby, move to a place where you will be notice
*Any pt who has receive interventions for an obstructed airway should be referred to a physician for examination ASAP
Assisted Ventilation
assisted ventilation is a technique of manually delivering atmospheric air and/or supplemental oxygen into the pts lungs
Assisted Ventilation is indicated for:
Resp arrest
Irregular Resp rates (I.e. lower than 10 breaths per minute or higher than 30 breaths per minute)
The most common vent devices are the resuscitation mask and the BVM
1. Maintain an open airway using the head-tilt-chin-lift of jaw thrust
2. Give one ventilation
every 5-6 seconds for an adult
every 3-5 seconds for a child
on inhalation and a second vent after exhalation if the pt has bradypnea
on every second inhalation if the pt is tachypneic
3. watch the chest
the chest should start to rise with each ventilation
CPR order
compressions → AED → Airway BVM
Do you pause CPR for any reason?
no
Airway Management
Normal Respiration Rates
Adult: 12-20
Child: 20-40
Infant: up to 60
Opening the Mouth
Crossed finger technique
1. Cross the thumb and index finger of one hand
2. Place the thumb on the pts lower front teeth and the index finger on the upper front teeth,
3. Open the mouth using a scissor motion
Tongue-Jaw Lift technique
1. Place your index finger beneath the pts chin
2. insert your thumb of the same hadn into the pts mouth and grasp the tongue between your thumb and finger.
3. Gently lift the mandible forward to open the pts mouth
Airway adjuncts
an airway adjunct (ex. OPA, NPA), may not suffice to maintain patency (openness) alone. Continuously monitor the pts resp after the insertion of an adjunct and use manual techniques (eg head tilt chin lift) as needed.
Oropharyngeal Airways
Indicated for unresponsive adults, children, and infants.
Available in a variety of sizes
will not interfere with assisted ventilation or oxygen delivery if properly sized and inserted
Will interfere with suctioning
Insertion
to properly insert an OPA. if the pt gags upon insertion they may be partially responsive. Stop your attempt. Maintain airway patency using other methos and continue your pt assessment. Reattempt insertion frequently.
Children and infants - have delicate airways practice extra caution to prevent injury, and avoid hyperextending the neck. To insert an OPA for a child, gently slide the tip along the inside of the cheek and then rotate 90 degrees to place in the throat. For an infant, place the padding under the shoulders to maintain a neutral position and avoid hyper extending the neck. Use a tongue depressor to hold the tongue against the lower lip with the concave side facing down, and slide the OPA smoothly into place without rotating it following the natural curve of the mouth and throat.
Removal
1. grasp the flange between your thumb and index
2. pull gently towards the pts chin; the OPA will slide out smoothly.
Nasopharyngeal Airway
Indicates for unresponsive and responsive adults
not indicated for pts with suspected skull fracture, epistaxis(nosebleeds) or facial trauma
available in a variety of sizes
will not interfere with suction
may cause epistaxis leading to blood in the airway
Insertion
1. measure the NPA and the lubricate it with a water soluble lubricant
2. insert the NPA into the right nostril with the bevel toward the septum
*Never force an NPA into the airway if it does not pass easily remove it and try the other nostril
Removal
grasp the flange gently between your thumb and index and gently draw it out.
Supraglottic Airway
When othe rairway managemnt is inefective, a supraglottic airway SGA is used to maintain airway potency, protect the airway and or provide onopstructed ventilation
An SGA is not indicated if you suspect a caustic substance has been injested or if the pt has
active vomiting
airway edema(swelling)
stridor (a high pitched sound when breathing due to a partial obstructed upper airway)
*Aspiration( taking blood, vomit, saliva or other foreign material into the lunfs) is a risk with supraglottic airway sespecially if the pt is gastric inflation or high airway pressure
Insertion
1. deflate the …
Suction
suctioning is a method of clearing forigh matter from the airway by using a manual or mechanical suction device.
A variety of suction devices are avsailbe. alwasy follow the instructions for the potper use and maintenence of your specific machine.
1. provide rapid suction until the airway is clear
2. after suctioning, provide suplemental ocygen
*A bulb syring is used to provide suction for an infanct. Deflate the bulb syringe before inserting it into the infants airway
Oxygen Therapy
Pulse oxymetry
pulse oxymetry is the non-invasice methof of measuring th epercentage of hemoglobin that is saturated with oxygen. the reading is recoded as a percentage of oxygen sat and is written as Spo2.
Initial Spo2 reading is the Room air sat. Also used to determine adequacy of oxygen delivery
* continue adminiserting high flow O2 to all pts with suspected CO poisoning regardless of the sat reading
Normal: 95-100. no treatment
Mild Hypoxia: 91-94. Administer emergency oxygen using a nasal canula or stnadard oxygen mask
Moderate hypoxia: 86-90. Administer emogency oxygen using a NRB or BVM with resevoir bag
Severe Hypoxia: 85 and lower. Administer emergency oxygen using NRB or BVM with recvoir
Supplemental Oxygen Delivery Devices
Nasal Cannula: Common flow rate of 1-4LPM. Oxygen Concentration of 24-36%. Function = Breathing pts only
Resuscitation Mask: Common flow rate of 6+LPM. Oxygen Concentration of 35-55%. Function = Breathing pts only
Standard Mask: Common flow rate of 6-10LPM. Oxygen Concentration of 40-60%. Function = Breathing pts only
NRB with O2 recevoir: Common flow rate of 10+LPM. Oxygen Concentration of 24-36%. Function = Breathing pts only
BVM with O2 recevoir: Common flow rate of 15LPM. Oxygen Concentration of 24-36%. Function = Breathing pts only