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  1. 1. Basic Cardiac Life Support (BCLS)Outline:  Definitions of basic cardiac life support  Purpose of cardiopulmonary resuscitation  Chain of Survival  changes in the BLS guidelines  Sequence of adult one-man CPR  Chest compression-only CPR  Two-person CPR  CPR Performance Mistakes  Pediatric basic cardiac life support  CPR sequences across age groups  Post-Procedure Complications o Regurgitation during CPR o Stomach (gastric) distension o Chest compression related injuries o Dentures, loose or broken teeth, or dental appliances  Defibrillation (Automated External Defibrillator (AED)) o Types of automated external defibrillator o Sequence of actions when using an automated external defibrillator o Placement of AED pads o Children‟s AEDs o Defibrillation if the victim is wet o Voice prompts o Public access defibrillation (PAD)  Relief of foreign body airway obstruction (FBAO)  References:Intended learning outcomeAfter review and study of these pages and attendance at an approved nursing skills lab thecritical care student should be able to:  Define basic cardiac life support  Recognize Purpose of cardiopulmonary resuscitation  Identify changes in the BLS guidelines  Demonstrate Sequence of one-man & two person CPR across age groups  Identify Post-Procedure Complications  Identify CPR Performance Mistakes  Recognize Defibrillation (Automated External Defibrillator (AED)  Demonstrate Sequence of relief of foreign body airway obstruction (FBAO) 1
  2. 2. Basic Cardiac Life Support (BCLS): is the foundation for saving lives following cardiac arrest Purpose of cardiopulmonary resuscitation The purpose of BLS is to maintain adequate ventilation and circulation until means can be obtained to reverse the underlying cause of the arrest. Failure of the circulation for three to four minutes (less if the casualty is initially hypoxemic) will lead to irreversible cerebral damage. The new BLS CPR guidelines consist of 3 main components: (compression, airway, and breathing (CAB)There are universal strategy actions for achieving successful resuscitation. Theseactions are termed the links in the “Chain of Survival.” For adults they include:  Immediate recognition of cardiac arrest and activation of the emergency response system  Early CPR that emphasizes chest compressions  Rapid defibrillation if indicated  Effective advanced life support  Integrated post– cardiac arrest care When these links are implemented in an effective way, survival rates can approach 50% following witnessed out-of hospital ventricular fibrillation (VF) arrest. 2
  3. 3. The following changes in the BLS guidelines have been made to reflect the importance placed onchest compression, particularly good quality compressions, and to attempt to reduce the numberand duration of pauses in chest compression: New Old Rationale Chest compressions, Airway, Breathing (C‐A‐B) New science indicates the Airway, Breathing, Chest Although ventilations are an following order: compressions (A‐B‐C) important part of 1. Check the patient for Previously, after resuscitation, evidence responsiveness. responsiveness was assessed, a shows that compressions 2. Check for no breathing or no call for help was made, theCPR are the critical element in normal breathing. airway was opened, the patient adult resuscitation. In the 3. Call for help. was checked for breathing, and ABC sequence, 4. Check the pulse for no 2 breaths were given, followed compressions are often longer than 10 seconds. by a pulse check and delayed. 5. Give 30 compressions. compressions 6. Open the airway and give 2 breaths. 7. Resume compressions. Compressions were to be given Compressions are often Compressions should be after airway and breathing delayed while providers initiated within 10 seconds of were assessed, ventilations open the airway and deliver recognition of the arrest. were given, and pulses were breaths. checked Compressions should be given Compressions were to be given Compression rates are at a rate of at least 100/min. at a rate of about 100/min. commonly quite slow, and Each set of 30 compressions Each cycle of 30 compressions compressions >100/min should take approximately 18 was to be completed in 23 result in better perfusion seconds or less. seconds or less. and better outcomes Compression depths are as follows: • Adults: at least 2 inches (5 Compression depths were as cm) follows: Deeper compressions • Children: at least one third • Adults: 1½ to 2 inches generate better perfusion of the depth of the chest, • Children: one third to one the coronary and cerebral approximately 2 inches (5 cm) half the diameter of the chest arteries. • Infants: at least one third the • Infants: one third to one depth of the chest, half the diameter of the chest approximately 1½ inches (4 cm) Randomized studies have Cricoid pressure is no longer If an adequate number of demonstrated that cricoidAirway & routinely recommended for use rescuers were available, one pressure still allows forBreathing with ventilations during could apply cricoid pressure. aspiration. It is also difficult cardiac arrest. to properly train providers 3
  4. 4. to perform the maneuver correctly. With the new chest compression–first sequence, “Look, listen, and feel for CPR is performed if the breathing” has been removed adult victim is unresponsive from the sequence for and not breathing or not assessment of breathing after breathing normally (i.e., not opening the airway. Healthcare breathing or only gasping) “Look, listen, and feel for providers briefly check for no and begins with breathing” was used to assess breathing or no normal compressions (C‐A‐B breathing after the airway was breathing when checking sequence). Therefore, opened responsiveness to detect signs breathing is briefly checked of cardiac arrest. After delivery as part of a check for of 30 compressions, lone cardiac arrest. After the first rescuers open the victim‟s set of chest compressions, airway and deliver 2 breaths. the airway is opened and the rescuer delivers 2 breaths. The lowest energy dose for For children from 1 to 8 years effective defibrillation in of age, an AED with a infants and children is not pediatric dose‐attenuator known. The upper limit for system should be used if safe defibrillation is also available. If an AED with a not known, but doses >4 dose attenuator is not available, This does not represent a J/kg (as high as 9 J/kg) have a standard AED may be used. change for children. In 2005 provided effective For infants (<1 year of age), a there was not sufficient defibrillation in childrenAED Use manual defibrillator is evidence to recommend for or and animal models of preferred. If a manual against the use of an AED in pediatric arrest, with no defibrillator is not available, an infants. significant adverse effects. AED with a pediatric dose AEDs with relatively high attenuator is desirable. If energy doses neither is available, an have been used successfully AED without a dose attenuator in infants in may be used. cardiac arrest, with no clear adverse effects Sequence of adult one-man CPR 1. S Safety 5. CCirculation 2. R Response 6. AAirway 3. A Activate EMS 7. BBreathing 4. P  Position 8. DDefibrillation 4
  5. 5. Steps Rationale1. Check for danger ( safety) This ensures that the rescuer operates in a safe environment2. Check for responsiveness and breathing The rescuer should tap the victim firmly and ask loudly, “Hello! Hello! Are you okay?” Do not move injured person to prevent further damage from occurring (e.g. if the patient has a spinal injury), and to assess the level of harm to the patient so the right actions are taken accordingly. If victim responds but injured. leave If unresponsive: shout for help, call him in his position, Phone 123, and „123‟ for an ambulance Reassess victim regularly3. Activate the emergency response system (EMS) Summon help to ensure Get an automated external defibrillator (AED) if there is one within a 90 emergency services arrive as seconds walking distance. Return to victim; provide CPR and defibrillation soon as possible. if needed. When phoning 123 for help, provide information about: For a drowning victim or  Location, victim of asphyxial arrest  What happened? (primary respiratory) of any age, give 5 cycles of CPR  Number and condition of victims (2minutes) before leaving the  Type of aid provided. victim to activate the EMS4. If victim is breathing with no response: put victim on recovery position, Placing a patient in the call for ambulance & check for continuous breathing recovery position gives gravity Recovery Position assistance to the clearance of The recovery position is used for unresponsive adult victims who clearly physical obstruction of the have normal breathing and effective circulation. airway by the tongue, and also This position is designed to maintain a patent airway and reduce the risk of gives a clear route by which airway obstruction and aspiration and enable the victim to be turned to his fluid can drain from the side and returned onto his back easily and safely, with due care taken for airway. possible cervical spine injury. Any pressure on the chest that impairs breathing should be avoided. The position should be stable, near a true lateral position, with the head dependent and with no pressure on the chest to impair breathing as following: 1. Place arm nearest to you out at RT angles to body, elbow bent with hand palm upper-most 5
  6. 6. 2. Bring far arm across chest, hold back of hand against victim‟s cheek nearest to you. 3. With your other hand, grasp the far leg just above knee; pull it up, keeping the foot on the ground. 4. Keep hand against his cheek, pull on far leg to roll victim towards you onto his side.5. Positioning The health care provider giving CPR is most easily and effectively performed by laying the patient supine compressions should be on a relatively hard surface, which allows effective compression of the positioned high enough above sternum. Delivery of CPR on a mattress or other soft material is generally the patient to achieve sufficient less effective. If found in prone position, roll the victim (log roll) to a leverage, so that he or she can supine position (face up). use body weight to adequately compress the chest. 6
  7. 7. In the hospital setting, where patients are in gurneys or beds, appropriate positioning is often achieved by lowering the bed, having the CPR provider stand on a step-stool, or both. In the out-of-hospital setting, the patient is often positioned on the floor, with the CPR provider kneeling over him or her. If the victim is not in face up (supine) position (Turn the victim on his back)  Straighten the legs  Position the closer arm above the victim‟s head  Grasp under the distant armpit  Cradle the head and neck  Move the patient as a unit onto his side then onto his back  Reposition the victim‟s extended arm...6. If no response and no or abnormal breathing Check Circulation: Pulse check not more than 10 seconds (for health provider only) Start Chest compressions Consist of forceful rhythmic applications of pressure over the lower half of the sternum. These compressions create blood flow by increasing intrathoracic pressure and directly compressing the heart. This generates blood flow and oxygen delivery to the myocardium and brain.  To provide effective chest compressions, push hard and push fast. The lay rescuer should not  To maximize the effectiveness of chest compressions, place the victim check for a pulse and should on a firm surface when possible, in a supine position with the rescuer assume that cardiac arrest is kneeling beside the victim‟s chest present if an adult suddenly  Compress the chest at a rate of at least 100 compressions per minute collapses or an unresponsive with a compression depth of at least 2 inches/5 cm victim is not breathing  Allow complete recoil of the chest after each compression, to allow the normally. heart to fill completely before the next compression, with chest Chest compressions are compression and chest recoil/relaxation times approximately equal extremely important. If you are  Minimize the frequency and duration of interruptions in compressions to not comfortable giving rescue maximize the number of compressions delivered per minute. No longer breaths, still perform chest than 10 seconds, except for specific interventions such as insertion of an compressions! Its called Hands advanced airway or use of a defibrillator Only CPR.  A compression-ventilation ratio of 30:2 is recommended until an during the first minutes of advanced airway is placed; then continuous chest compressions with sudden VF cardiac arrest, ventilations at a rate of 1 breath every 6 to 8 seconds (8 to 10 rescue breaths are not as 7
  8. 8. ventilations per minute) should be performed. important as chestTechnique of chest compressions compressions because the • The sternum (breastbone) may be exposed; however, especially in oxygen content in the non cases of a female victim, chest compressions may be done through circulating arterial blood the clothes. remains unchanged until CPR • The site of compression should be at the center of the chest/loweris started; the blood oxygen half of the sternum. content then continues to be(a)Kneel by the side of the victim adequate during the first several minutes of CPR. In(b)Run the middle finger along the lower margin of the victim‟s ribcage on addition, attempts to open the the near side till you reach the notch at the center. Place your index airway and give rescue breaths finger next to it. (or to access and set up airway equipment) may delay the(c)Place the heel of the palm of the other hand on the lower half of the initiation of chest compressions sternum (breastbone) next to the index finger.(d)Place the heel of the first hand on top of the second. Continuous compressions allow a build-up of pressure in(e)Interlace the fingers of both hands and lift the fingers off the chest wall. the aorta, which in turn maintains flow to both the myocardium and the brain. Whenever there is a break in compressions to allow ventilation or to perform some other manoeuvre, the pressure within the aorta drops. To ensure adequate oxygenation of vital organs(f)Straighten both elbows and lock them into position. Incomplete recoil during BLS CPR is associated with higher(g)Position shoulders directly over the victim‟s chest. Use your body intrathoracic pressures and weight to compress the victim‟s breastbone. significantly decreased hemodynamic, including decreased coronary perfusion, cardiac index, myocardial blood flow, and cerebral perfusion. 8
  9. 9.  Depth of chest compression for adults must be at least 5 cm.  Compression rate is at least 100 per minute. Allow complete recoil of the chest wall after each compression.  Counting aloud of the compressions below is encouraged  Every 30 chest compressions should be followed promptly by two quick and short ventilations (each 400–600 ml tidal volume so that the chest just rises) delivered within six seconds.  Checking for return of spontaneous circulation7. Open airway Head tilt-chin lift maneuver for victim without evidence of head or neck Ensures the airway is open as trauma. Hands on forehead gently tilt his head back. (Keep your thumb and the process allows the tongue index finger free to close his nose if rescue breathing is required). With to be lifted from the back of the fingertips, lift chin throat. and ensures lungs are safe from aspiration Because maintaining a patent airway and providing adequate ventilation are priorities in CPR, use the head tilt–chin lift maneuver if the jaw thrust does not adequately open the airway. Jaw-thrust maneuver: if suspecting cervical spine injury. Grasp angles of lower jaw and lift with both hands, one on each side, displacing mandible forward while tilting the head backward, if the lips close, and retreat lower lip with the thumb. 9
  10. 10. 8. Begin rescue breathing: (Gasping is not considered normal breathing). Give 2 rescue breathing deliver rescue breaths by mouth-to-mouth or bag-mask to provide oxygenation and ventilation, as follows: ● Deliver each rescue breath over 1 second. ● Give a sufficient tidal volume to produce visible chest rise ● Use a compression to ventilation ratio of 30 chest compressions to 2 ventilations ●The rescuer delivering ventilation can provide a breath every 6 to 8 Taking a regular rather than a seconds (which yields 8 to 10 breaths per minute). deep breath prevents the ● When an advanced airway (i.e., endotracheal tube, Combi tube, or rescuer from getting dizzy or laryngeal mask airway [LMA]) is in place during 2-person CPR, give 1 lightheaded and prevents over breath every 6 to 8 seconds without attempting to synchronize breaths inflation of the victim‟s lungs. between compressions (this will result in delivery of 8 to 10 breaths/minute). Ensures adequate ventilation There should be no pause in chest compressions for delivery of ventilations and perfusion; ensures air is Mouth-to-Mouth Rescue breathing going into the patient‟s lungs.  Open victims airway  Pinch nose with thumb & index finger  Take a regular breath  Create an airtight mouth-to-mouth seal  Give 1st rescue breathe over 1 sec. 10
  11. 11. If victims chest does not rise with 1st rescue breathe, then before next attempt  Check victims mouth & remove any obstruction  Perform head tilt-chin lift maneuver  Give the 2nd rescue breath. Mouth-to-nose ventilation is recommended if ventilation through the victim‟s mouth is impossible Give mouth-to-stoma rescue breaths to a victim with a tracheal stoma who requires rescue breathing. If more than one rescuer is present, the process of CPR should be shared at To facilitate effective a rate of approximately 1-2 minutes. resuscitation and avoid rescuer tiredness. Ensure the minimum of delay during the changeover of rescuers, and do not To maintain consistency of the interrupt chest compressions. CPR process. Continue resuscitation until: To ensure adequate Qualified help arrives and takes over oxygenation of vital organs and The patient starts to show signs of regaining consciousness, such as airway patency. coughing, opening their eyes, speaking, or moving purposefully AND starts to breathe normally, OR you become exhausted9. Early Defibrillation with an AED(if available) VF is a common and treatable If you have access to an automated external defibrillator (AED), continue to initial rhythm in adults with do CPR until you can attach it to the victim and turn it on. If you saw the witnessed cardiac arrest. Rapid victim collapse, put the AED on right away. If not, attach it after defibrillation is the treatment approximately one minute of CPR (chest compressions and rescue breaths). of choice for VF of short Defibrillation Sequence duration ● Turn the AED on. ● Follow the AED prompts. ● Resume chest compressions immediately after the shock (minimize interruptions). Chest compression-only CPR Compression-only CPR is usually only instructed during dispatcher-assisted CPR. In addition, lay rescuers who are unable, or for some reason, unwilling to provide mouth-to-mouth ventilations should be encouraged to at least perform good chest compressions. Two-person CPR • If there is more than one rescuer, one person should call for the ambulance (123) to activate the emergency respond system and get the AED once the victim is found to be unresponsive. The 11
  12. 12. other continues to check for breathing (and pulse for trained healthcare providers only) and starts chest compressions, if needed. • Rescuers should take turns to perform CPR every two minutes (or around five cycles of 30 chest compressions: two ventilations) as fatigue may set in. This change-over should involve minimal interruption of chest compressions. • Two-person CPR may be more efficient with one person doing the ventilations and the other doing the chest compressions CPR Performance MistakesRescue Breathing Mistakes Chest Compression Mistakes  Pivoting at knees.  Wrong compression site.  Inadequate head tilt.  Bending elbows.  Failing to pinch nose shut.  Shoulders not above sternum.  Not giving slow breaths.  Fingers touching chest.  Failing to watch chest raising.  Heal of bottom hand not in line with sternum.  Failing to maintain tight seal around  Placing palm on sternum. victims mouth (and or nose( .  Lifting hands off chest between compressions.  Incorrect compression rate and /or ratio.  Jerky or japping compressions. 12
  13. 13. 13
  14. 14. Pediatric Basic Life Support American Heart Association (AHA) pediatric Chain of Survival includes 1. Prevention, 2. Early cardiopulmonary resuscitation (CPR), 3. Prompt access to the emergency response system, 4. Rapid pediatric advanced life support (PALS), 5. Integrated post– cardiac arrest care Infants are less likely to survive out-of hospital cardiac arrest (4%) than children (10%) or adolescents (13%), presumably because many infants included in the arrest figure are found dead after a substantial period of time, most from sudden infant death syndrome (SIDS). Sequence of steps Rationale1. Prevention of Cardiopulmonary Arrest In children over 1 year of age, injury is the leading cause of death.2. Safety of rescuer and victim Barrier Devices Barrier devices have not reduced the low risk of transmission of infection and some may increase resistance to air flow If you use a barrier device, do not delay rescue breathing. If there is any delay in obtaining a barrier device or ventilation equipment, give mouth- to-mouth ventilation (if willing and able) or continue chest compressions alone3. Assess need for CPR If the victim is unresponsive and not breathing or only gasping4. Check for Response Gently tap the victim and ask loudly, “Are you okay?”  If the child is responsive,he or she will answer, move, or moan;Quickly check to see if the child has any injuries or needsmedical assistanceIf you are alone and the child is breathing, leave the child tophone the emergency response system, but return quickly andrecheck the child‟s condition frequently 14
  15. 15. Allow the child with respiratory distress to remain in a positionthat is most comfortable  If the child is unresponsive, Most infants and children with cardiac arrestShout for help have an asphyxial rather than a VF arrest2 minutes of CPR are recommended before the lone rescueractivates the emergency response system and gets an AED ifone is nearby.5. Check for Breathing  If you see regular breathing, the victim does not need CPR.  If there is no evidence of trauma, turn the child onto the side (recovery position), which helps maintain a patent airway and decreases risk of aspiration.  If the victim is unresponsive and not breathing (or only gasping), begin CPR6. Pulse Check ( trainer only) Start Chest CompressionsTake up to 10 seconds to attempt to feel for a pulse (brachial inan infant and carotid or femoral in a child). During cardiac arrest, high-quality chest  Inadequate Breathing with Pulse compressions generate blood flow to vitalIf there is a palpable pulse 60 per minute but there is inadequate organs and increase the likelihood of ROSC.breathing, give rescue breaths at a rate of about 12 to 20 breathsper minute (1 breath every 3 to 5 seconds) until spontaneous Hands-Only (Compression-Only) CPRbreathing resumes Optimal CPR in infants and children includesReassess the pulse about every 2 minutes but spend no more both compressions and ventilations, butthan 10 seconds doing so compressions alone are preferable to no CPR  Bradycardia with Poor PerfusionIf the pulse is 60 per minute and there are signs of poorperfusion (i.e., pallor, mottling, and cyanosis) despite supportof oxygenation and ventilation, begin chest compressions.The following are characteristics of high-quality CPR: Chest compressions of appropriate rate and depth. “Push fast”: push at a rate of at least 100 compressions per minute. “Push hard”: push with sufficient force to depress at least (Incomplete recoil during CPR is associated one third the anterior-posterior (AP) diameter of the chest or with higher intrathoracic pressures and approximately 1 1⁄2 inches (4 cm) in infants and 2 inches (5 significantly decreased venous return, cm) in children. coronary perfusion, blood flow, and cerebral Allow complete chest recoil after each compression to allow perfusion), because complete chest re- the heart to refill with blood. expansion improves the flow of blood Minimize interruptions of chest compressions. returning to the heart and thereby blood flow Avoid excessive ventilation. to the body during CPR For best results, deliver chest compressions on a firm surfaceFor an infant, lone rescuersShould compress the sternum with 2 fingers placed just belowthe intermammary lineDo not compress over the xiphoid or ribs. Rescuers should 15
  16. 16. compress at least one third the depth of the chest, or about 4 cm(1.5 inches).The 2 thumb encircling hands technique is recommended when The 2 thumb encircling hands technique isCPR is provided by 2 rescuers. Encircle the infant‟s chest with preferred over the 2 finger technique becauseboth hands; spread your fingers around the thorax, and place it produces higher coronary artery perfusionyour thumbs together over the lower third of the sternum. pressure, results more consistently inForcefully compress the sternum with your thumbs. appropriate depth or force of compression and may generate higher systolic and diastolic pressuresFor a child,Compress the lower half of the sternum at least one third of theAP dimension of the chest or approximately 5 cm (2 inches)with the heel of 1 or 2 hands. Do not press on the xiphoid or theribs.After each compression, allow the chest to recoil completely7. Open the Airway and Give VentilationsOpen the airway using a head tilt– chin lift maneuver for both In an unresponsive infant or child, the tongueinjured and non injured victims To give breaths to an infant, use may obstruct the airway and interfere witha mouth-to-mouth-and nose technique. ventilations. 16
  17. 17. To give breaths to a child, use a mouth-to mouth technique.Each breath should take about 1 second. If the chest does notrise, reposition the head, make a better seal, and try againBag-Mask Ventilation (Healthcare Providers) notrecommended for a lone rescuer during CPR Bag-mask ventilation requires training andUse a self-inflating bag with a volume of at least 450 to 500 mL periodic retraining in the following skills:for infants and young children, as smaller bags may not deliver Selecting the correct mask size, opening thean effective tidal volume or the longer inspiratory times airway, making a tight seal between the maskrequired by full-term neonates and infants and face, delivering effective ventilation, andIn older children or adolescents, an adult self-inflating bag assessing the effectiveness of that ventilation.(1000 mL) may be needed to reliably achieve chest riseAttach self-inflating bag to o2 source by 10-15 ml to deliveroxygen concentration 60%-80 %Effective bag-mask ventilation requires a tight seal between themask and the victim‟s face. Open the airway by lifting the jawtoward the mask making a tight seal and squeeze the bag untilthe chest rises8. Coordinate Chest Compressions and Breathing(The ideal compression-to-ventilation ratio in infants andchildren is unknown.)For 2-rescuer infant and child CPR, one provider shouldperform chest compressions while the other keeps the airwayopen and performs ventilations at a ratio of 15:2. Deliverventilations with minimal interruptions in chest compressionsThe ventilation rescuer delivers 8 to 10 breaths per minute (abreath every 6 to 8 seconds), being careful to avoid excessiveventilation in the stressful environment of a pediatric arrest.The lone rescuer should continue this cycle of 30 compressionsand 2 breaths for approximately 2 minutes (about 5 cycles)before leaving the victim to activate the emergency responsesystem and obtain an automated external defibrillator (AED) ifone is nearby.9. Defibrillation VF can be the cause of sudden collapse orFor manual pediatric defibrillator t the recommended first may develop during resuscitation attempts.energy dose for defibrillation is 2 J/kg. If a second dose is Children with sudden witnessed collapserequired, it should be doubled to 4 J/kg. (e.g., a child collapsing during an athletic event) are likely to have VF or pulseless VTIf a manual defibrillator is not available, an AED equipped with and need immediate CPR and rapida pediatric attenuator is preferred for infants and children 8 year defibrillation. VF and pulseless VT areof age. If neither is available, an AED without a dose attenuator referred to as “shockable rhythms” becausemay be used they respond to electric shocks (defibrillation).The AED will prompt the rescuer to re-analyze the rhythmabout every 2 minutes. Shock delivery should ideally occur assoon as possible after compressions. 17
  18. 18. Defibrillation Sequence Using an AED  Turn the AED on.  Follow the AED prompts.  End CPR cycle (for analysis and shock) with compressions, if possible  Resume chest compressions immediately after the shock.  Minimize interruptions in chest compressions 18
  19. 19. Post-Procedure Complications 1. Regurgitation during CPRRegurgitation of stomach contents is common during CPR (particularly in victims of drowning)due to artificial respiration using noninvasive ventilation methods (e.g., mouth-to-mouth, bag-valve-mask [BVM]) which result in gastric insufflation. This can lead to vomiting, which canfurther lead to airway compromise or aspiration.If regurgitation occurs:  Turn the victim away from you.  Keep him on his side and prevent him from toppling on to his front.  Ensure that his head is turned towards the floor and his mouth is open and at the lowest point, thus allowing vomit to drain away.  Clear any residual debris from his mouth with your fingers; and immediately turn him on to his back, re-establish an airway, and continue rescue breathing and chest compressions at the recommended rate 2. Stomach (gastric) distensionCauses:-  Rescue breathes given too fast.  Rescue breathes given too forcefully.  Partially or completely blocked airway.Prevention:-  Blow just hard enough to make chest rise.  Keep the airway open during inhalations and exhalations.  Use mouth to nose method.  Re tilt head to open airway. 3. Chest compression related injuriesTypes:-  Rib fractures.  Rib separation.  Air and / or blood in chest cavity -Bruised lung.  Lacerations of the lung, liver, or spleen.Prevention:-  Use proper hand location on chest.  Keep fingers off victims rib.  Press straight down.  Give smooth, regular and uninterrupted compression.  Avoid pressing chest too deeply. 4. Dentures, loose or broken teeth, or dental appliancesPrevention:-  Leave tight fitting dentures in place.  Remove loose or broken teeth, dentures, and/or dental appliances. 19
  20. 20. CPR sequences across age groups Adult and older Child (1–8 years of CPR sequence Infant (< 1 year of age) child age)Establish Immediately After 2 minutes CPRunresponsiveness;call 123, get AED Unresponsive (for all ages) No breathing or noRecognition normal breathing No breathing or only gasping (i.e., only gasping) No pulse palpated within 10 seconds for all ages (HCP only)CPR sequence C-A-BOpen airway Head tilt – chin lift(HCP suspected trauma: jaw thrust)Pulse check Carotid BrachialStart chest compressions If no normal breathing or pulse Lower half of sternumCompression landmarks Lower half of sternum (just below intermammary line)Compression method Heel of one hand, other on top Two fingers At least one third the At least one third the depth of the chest, At least 2 inches depth of the chest, approximately 1½ inchesCompression depth (5 cm) approximately 2 (4 cm) Press with the inches (5 cm) heel of one hand in children.Compression rate At least 100/min Allow complete recoil between compressionsChest wall recoil HCPs rotate compressors every 2 minutesCompression: ventilation 30:2 Single rescuer 30:2 (1 or 2 rescuers)ratio 15:2 two HCP rescuersCompression Minimize interruptions in chest compressionsinterruptions Attempt to limit interruptions to <10 seconds Two breaths at one second per breath. Should not interrupt chestBreathing compressions for more than six seconds to perform the two breaths.Ventilations: when rescueruntrained or trained and Compressions onlynot proficient 1 breath every 6-8 seconds (8-10 breaths/min)Ventilations with Asynchronous with chest compressionsadvanced About 1 second per breathairway (HCP) Visible chest rise Attach and use AED as soon as available. Minimize interruptions inDefibrillation chest compressions before and after shock; resume CPR beginning with compressions immediately after each shock 20
  21. 21. Automated External Defibrillator (AED) USEAEDs are sophisticated, reliable, safe, computerized devices that deliver electric shocks tovictims of cardiac arrest when the ECG rhythm is one that is likely to respond to a shock.Types of automated external defibrillatorAll AEDs analyze the victim‟s ECG rhythm and determine the need for a shock. The semi-automatic AED indicates the need for a shock, which is delivered by the operator, while the fullyautomatic AED administers the shock without the need for intervention by the operator. Somesemi-automatic AEDs have the facility to enable the operator (normally a healthcareprofessional) to override the device and deliver a shock manually, independently of prompts. Sequence of actions1. Follow the adult BLS sequence. Do not delay starting CPR unless the AED isavailable immediately.2. as soon as the AED arrives:  If more than one rescuer is present, continue CPR while the AED is switched on. If you are alone, stop CPR and switch on the AED.  Follow the voice / visual prompts.  Attach the electrode pads to the patient‟s bare chest.  Ensure that nobody touches the victim while the AED is analyzing the rhythm.3A. if a shock is indicated: 3B. if no shock is indicated:  Ensure that nobody touches the  Resume CPR immediately using a victim. ratio of 30 compressions to 2 rescue 21
  22. 22.  Push the shock button as directed breaths. (fully-automatic AEDs will deliver  Continue as directed by the voice / the shock automatically). visual prompts.  Continue as directed by the voice / visual prompts.  Minimize, as far as possible, interruptions in chest compression4. Continue to follow the AED prompts until:  Qualified help arrives and takes over  The victim starts to show signs of regaining consciousness, such as coughing, opening his eyes, speaking, or moving purposefully AND starts to breathe normally  You become exhausted 22
  23. 23. Placement of AED pads  Place one AED pad to the right of the sternum (breast bone), below the clavicle (collar bone). Place the other pad in the left mid-axillary line, approximately over the position of the V6 ECG electrode. It is important that this pad is placed sufficiently laterally and that it is clear of any breast tissue.  Although most AED pads are labeled left and right, or carry a picture of their correct placement, it does not matter if their positions are reversed. It is important to teach that if this happens „in error‟, the pads should not be removed and replaced because this wastes time and they may not adhere adequately when re-attached.  The victim‟s chest must be sufficiently exposed to enable correct pad placement. Chest hair will prevent the pads adhering to the skin and will interfere with electrical contact.  Shave the chest only if the hair is excessive, and even then spend as little time as possible on this. Do not delay defibrillation if a razor is not immediately available.Children’s AEDsProvide 5 cycles of CPR, 30 compression to 2 breaths, for 2 minutes before using an AED on achild from 1 year to 8 or on an infant 1< of age.Standard AED pads are suitable for use in children older than 8 years. Special pediatric pads, thatattenuate the current delivered during defibrillation, should be used in children aged between 1and 8 years if they are available; if not, standard adult-sized pads should be used. The use of anAED is not recommended in children aged less than 1 year. However, if an AED is the onlydefibrillator available its use should be considered.Defibrillation if the victim is wetAs long as there is no direct contact between the user and the victim when the shock is delivered,there is no direct pathway that the electricity can take that would cause the user to experience ashock. Dry the victim‟s chest so that the adhesive AED pads will stick and take particular care toensure that no one is touching the victim when a shock is delivered.Voice promptsThe sequence of actions and voice prompts provided by an AED are usually programmable andit is recommended that they be set as follows:  Deliver a single shock when a suitable rhythm is detected;  No rhythm analysis immediately after the shock;  A voice prompt for resumption of CPR immediately after the shock;  A period of 2 min of CPR before further rhythm analysis.Public access defibrillation (PAD)Public access defibrillation is the term used to describe the use of AEDs by laypeople.Two basic strategies are used. In the first, AEDs are installed in public places and used by peopleworking nearby. In a complementary strategy, first responders are dispatched by an ambulancecontrol centre when they might reach a patient more quickly than a conventional ambulance.The greater delay in defibrillation resulting from the need for such responders to travel to apatient has been associated with more modest success rates. However, this strategy does enabletreatment of people who arrest at home, the commonest place for cardiac arrest to occur. 23
  24. 24. Relief of Foreign Body Airway Obstruction (FBAO)Recognition of FBAO:Because recognition of choking (airway obstruction by a foreign body) is the key to successfuloutcome, it is important not to confuse this emergency with fainting, heart attack, seizure, orother conditions that may cause sudden respiratory distress, cyanosis, or loss of consciousness.Foreign bodies may cause either mild or severe airway obstruction.Choking occurs while eating and the victim may clutch his throat.• If the victim is coughing effectively, this means that the airway is mildly obstructed. Do not interfere. Allow the victim to expel the object himself by coughing.• In severe airway obstruction, the victim is unable to speak, breathe or cough effectively, and that requires immediate action. The Heimlich manoeuvre, also known as the abdominal thrust, is recommended for the relief of FBAO in responsive adults (> eight years of age) and children (1–8 years of age).The signs and symptoms enabling differentiation between mild and severe airway obstruction aresummarized in the table below. It is important to ask the conscious victim „Are you choking?‟ 24
  25. 25. Sequence for the treatment of adult choking(This sequence is also suitable for use in children over the age of 1 year)1. If the victim shows signs of mild airway obstruction: Encourage him to continue coughing, but do nothing else.2. If the victim shows signs of severe airway obstruction and is conscious: (Give up to five back blows)  Stand to the side and slightly behind the victim. 25
  26. 26.  Support the chest with one hand and lean the victim well forwards so that when the obstructing object is dislodged it comes out of the mouth rather than goes further down the airway. Give up to five sharp blows between the shoulder blades with the heel of other hand. Check to see if each back blow has relieved the airway obstruction. The aim is to relieve the obstruction with each blow rather than necessarily to give all five. If five back blows fail to relieve the airway obstruction give up to five abdominal thrusts. Stand behind the victim and put both arms round the upper part of his abdomen. Lean the victim forwards. Clench fist and place it between the umbilicus (navel) and the bottom end of the sternum (breastbone). 26
  27. 27.  Grasp this hand with other hand and pull sharply inwards and upwards.  Repeat up to five times.  If the obstruction is still not relieved, continue alternating five back blows with five abdominal thrusts.3. If the victim becomes unconscious: 1. Support and position the victim on his/her back on a firm, flat surface, wherever possible. 2. The rescuer should shout for help and activate the emergency ambulance by calling 123. 3. Begin 30 chest compressions immediately. 4. Then, open the airway by tilting the head and lifting the chin. The rescuer should look for the foreign object in the mouth, and if found, remove it. 5. Check for normal breathing. 6. If breathing is absent, attempt 1ventilation. 7. If the chest does not rise, re position the airway with the head tilt, chin lift procedure. 8. Attempt second ventilation. 9. Perform 30 chest compressions and then proceed back to head tilt, chin lift and check for foreign body. 10. Repeat steps 4-8 above until help arrives and takes over, or when the patient starts breathing, coughing, talking or moving.Following successful treatment for choking, foreign material may nevertheless remain in theupper or lower respiratory tract and cause complications later. Victims with a persistent cough,difficulty swallowing, or with the sensation of an object being still stuck in the throat shouldtherefore be referred for an immediate medical opinion.Choking While AloneIf you choke while you are alone, use your fists to do thrusts on yourself. Or lean over the backof a chair and press hard to pop out the object. 27
  28. 28. Baby (Younger Than 1 Year)FBAO may cause mild or severe airway obstruction. When the airway obstruction is mild, thechild can cough and make some sounds. When the airway obstruction is severe, the victimcannot cough or make any sound.If the baby can cough or make sounds, let him or her cough to try to get the object out. call 123If a baby cant breathe, cough, or make sounds, then:  Put the baby face down on your forearm so the babys head is lower than his or her chest.  Support the babys head in your palm, against your thigh. Dont cover the babys mouth or twist his or her neck.  Use the heel of one hand to give up to 5 back slaps between the babys shoulder blades.  If the object does not pop out, support the babys head and turn him or her face up on your thigh. Keep the babys head lower than his or her body.  Place 2 or 3 fingers just below the nipple line on the babys breastbone and give 5 quick chest thrusts (same position as chest compressions in CPR for a baby).  Keep giving 5 back slaps and 5 chest thrusts until the object comes out or the baby faints.  Abdominal thrusts are not recommended for infants because they may damage the infant‟s relatively large and unprotected liver. 28
  29. 29.  If the baby faints, call 123(if you havent called already). Then: o Do not do any more back slaps or chest thrusts. o Start CPR. After 30 chest compressions open the airway. If you see a foreign body, remove it but do not perform blind finger sweeps because they may push obstructing objects farther into the pharynx and may damage the oropharynx. o Attempt to give 2 breaths and continue with cycles of chest compressions and ventilations until the object is expelled. o After 2 minutes, if no one has already done so, activate the emergency response system.References: 1. Huntsville Hospital Training Center. American Heart Association, Basic Life Support for Healthcare Providers & Renewal Course April 2011: 1 of 14 2. Lim Sh. Basic Cardiac Life Support: 2011 Singapore guidelines, Singapore Medical Journal 2011; 52(8): 538-43 3. Charles D. Deakina, Jerry P. Nolanb, Kjetil Sundec, Rudolph W. Kosterd. European Resuscitation Council Guidelines for Resuscitation 2010, Resuscitation 2010; 81: 1282– 138 4. Jerry P. Nolan. Resuscitation guidelines 2010. The Resuscitation Council (UK), Tavistock, London 2010: 1- 156. 5. [Guideline] Berg RA, Hemphill R, Abella BS, et al. Part 5: Adult Basic Life Support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010; 122: 685-705. 6. Field JM, Hazinski MF, Sayre MR, et al. Part 1: executive summary: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. Nov 2 2010; 122: 640-56. 7. Field JM, Hazinski MF, Sayre M, et al. Part 1: Executive Summary of 2010 AHA Guidelines for CPR and ECC. Circulation 2010;122 (3):690 –719. 29