Basic Cardiac Life Support for Health Care Providers

Adults / Child / Infant

Introduction Cardiac emergencies are the most common

medical emergencies in the U.S., with over 600,000 deaths each year and more than half of them occur outside of hospitals.

EMERGENCY CARDIAC CARE-Involves:

Recognizing early warning signs of cardiac arrest (reassure victim/activate EMS).

Provide immediate BLS. Provide ACLS. Transfer to hospital

Early signs of cardiac arrest Unresponsiveness No breathing No signs of circulation

Causes of cardiac arrest: Trauma, drowning, choking, heart

attack….etc

CARDIOPULMONARY RESUSCITATION (CPR)

CPR: Consists of series of assessments & interventions that support cardiac and respiratory functions.

Main purpose of CPR is to provide oxygenated blood to the brain and heart

NO SPECIAL EQUIPMENTS ARE NEEDED- JUST HANDS AND MOUTH & STEP BY STEP PROCEDURE.

Chain of Survival for Adult

Assessment of unresponsiveness

Tap or gently shake the victim and shout “Are you ok”. To elicit a response a painful stimulus can be applied such as pinching the earlobe and pressing over the eyelid and observing for grimacing. Other associations recommend rubbing on the sternum using the knuckles of the fingers.

Activate EMS Rescuer who is alone should

alter sequence of rescue based on most likely cause.

Sudden witnessed collapse (likely VF) arrest activates EMS, get AED, do CPR.

Hypoxic arrest (i.e., suffocation give 5 cycles of CPR (about 2 minutes) before alerting EMS.

If there is no response, Call ***** and return to the victim. In most locations the emergency dispatcher can assist you with CPR instructions

Positioning the victim: Place the victim

first on His/ Her back on hard surface. If the victim is lying face down, turn or roll the victim as unit, supporting the head and neck

AIRWAY

Open the airway by the head tilt / chin lift maneuver for all victims

Health care personnel use: Jaw thrust in trauma patient CHIN LIFT

Cont. AIRWAY

BREATHING Assessment of

breathlessness (5-10 seconds)

Place your ear just one inch above the mouth and the nose of the victim and perform the following: LOOK: for the chest

to rise and fall LISTEN: for air

escaping during exhalation, and

FEEL: for the flow of air on your cheek

Cont BREATHING If breathing is not present

or is inadequate, begin rescue breathing by giving two slow breaths: pinch nose and cover the mouth with yours and blow until you see the chest rise. Give 2 breaths. 

Time: Each breath should take one

second and watch for chest rise and allow time for exhalation.

Volume: Sufficient volume. No large volume or forceful

breathing.

Circulation Assessment of pulselessness

(5-10 secs.): check for carotid/femoral artery pulse.

While maintaining the head tilt with one hand, locate the victim’s Adams apple (thyroid cartilage) with two or three fingers of the other hand. Slide your fingers into the groove between the Adam’s apple and the muscle on the side nearest you where the carotid pulse can be felt. Femoral artery pulse also can be checked.

If pulse is not definitely felt within 10 seconds, proceed with chest compression

TO LOCATE THE LANDMARK FOR EXTERNAL CHEST COMPRESSION

The technique of costal margin that is as follows:

1. Run your index and middle fingers up the lower margin of the rib cage and locate the sternal notch with your middle finger. The index finger is place next to the middle finger on the lower and of the sternum.

CONT. TO LOCATE THE LANDMARK FOR EXTERNAL CHEST COMPRESSION

2. The heel of the other hand (the one nearest the victim’s head) is placed on the lower half of the sternum, and the other hand is placed on the top of the hand on the sternum so that the hands are parallel.

CONT. TO LOCATE THE LANDMARK FOR EXTERNAL CHEST COMPRESSION

3. Your fingers may be either extended or interlaced but must be kept off the chest.

CONT. TO LOCATE THE LANDMARK FOR EXTERNAL CHEST COMPRESSION

4. Lock your elbows into position, the arms are straightened and shoulders directly over the victim’s sternum. Keep the heel of your hand lightly in contact with the chest during the relaxation phase of chest compression to maintain correct hand position.

CONT. Circulation

PUSH HARD- PUSH FAST: equal compression and relaxation allowing recoil of chest wall.

Chest compression – ventilation 30: 2, for 5 cycles (2 minutes rate of 100 per minute.

Depth of 1.5 to 2 inches.

Reassessment After 5 cycles of compressions and

ventilations (30:2), check for return of carotid pulse/ femoral pulse and spontaneous breathing.

According to the findings (after 2 minutes): There is pulse – place in the

recovery position, monitor vital signs until EMS arrives.

There is pulse but no breathing: continue rescue breathing every 5- 6 seconds (10-12 breaths). Recheck pulse every 2 minutes.

No pulse or breathing continue CPR 30:2. , until AED arrives or ACLS provider arrives.

HOW TO PLACE THE VICTIM IN THE RECOVERY POSITION

ONE MAN CPR, CHILD BELOW 8 YEARS OLD

Assessment of unresponsiveness Tap the child and shake and shout “ARE YOU

OK” to elicit a response, the same as in adult. If unresponsive shout for help and start CPR

immediately. If second rescuer or some one is available, have him or her activate the EMS system. Remind the activator the number is (********).

Activate EMS after 2 minutes CPR except in sudden witnessed collapse, activate immediately.

Position the victim in supine, on a firm, flat surface. Careful handling of the neck during positioning of victim

AIRWAY Open the airway: perform head-tilt, chin lift maneuver

BREATHING Assessment of breathlessness – (5-10 seconds) Place your ear just one inch above he mouth and the

nose of the victim and perform the following.1. LOOK for the chest to rise and fall2. LISTEN for air escaping during exhalation, and 3. FEEL for the flow of air on your cheek

If breathing is not present or is inadequate, begin

rescue breathing by giving two slow breaths: pinch nose and cover the mouth with yours and blow until you see the chest rise. Give 2 breaths.  Time: Each breath should take one second and watch

for chest rise and allow time for exhalation. Volume – sufficient volume. No large volume or

forceful breathing.

Assessment of Pulselessness (5-10 seconds) CHECK COROTID/ FEMORAL PULSE

If the pulse is weak or absent begin external chest compressions

Nipple line technique is not to be used; that is as follows: Run your index and middle fingers along the lower

rib cage until the middle finger reaches the notch. The index finger is placed next to the middle finger.

The heel of the same hand is placed next hand is placed next to the point where the index finger was located. (One or two hands can be used.)

CIRCULATION

Lock your elbows into position, the arms are straightened and shoulders directly over the victim’s sternum. Keep the heel of your hand lightly in contact with the chest during the relaxation phase chest compression to maintain correct hand position.

PUSH HARD- PUSH FAST WITH OUT ANY INTERUPTION

RATE OF COMPRESSION: 100 PER MINUTE

DEPTH OF COMPRESSIN: 1/3 -1/2 THE DEPTH OF THE CHEST

COMPRESSION /VENTILATION RATION: 30:2

COMPRESSION / RELAXATION CYCLE SHOULD BE EQUAL

Reassessment:- After 5 cycles of compressions

and ventilations (30:2), check for Return of carotid pulse/ femoral

pulse and spontaneous breathing. According to the findings (after 2

minutes): There is pulse – place in the

recovery position carefully; monitor vital signs until EMS arrives.

There is pulse but no breathing: continue rescue breathing every 3-5 seconds (12-20 breaths per minute). Recheck pulse every 2 minutes.

No pulse or breathing continue CPR 30:2. , until AED arrives or ACLS provider arrives

ONE MAN CPR, INFANT (TO APPROXIMATE 1 YEAR)

Cardio pulmonary arrest in infants and children is not usually a sudden event. Instead, it is often the end- result of a progressive deterioration in respiratory an circulatory function.

Assessment of unresponsiveness. Tap the child and shake and shout “ARE YOU OK” to

elicit a response, If unresponsive start CPR immediately. If second

rescuer or some one is available, have him or her activate the EMS system.

Activate EMS after 2 minutes CPR except in sudden witnessed collapse, activate immediately. Position the victim in supine, firm and flat surface.

AIRWAY Open the airway:

apply head tilt- chin lift to ‘sniffing’ or neutral position.

HCP CAN USE JAW THRUST IN TRAUMA PATIENT

BREATHING Assessment of breathlessness (5-10 seconds) Place your ear just one inch above the mouth and the

nose of the infant and perform the following. LOOK for the chest to rise and fall LISTEN for air escaping during exhalation FEEL for the flow of air on your check

If the breathing is not present or is inadequate , make a tight seal over the mouth and the nose of the infant and begin rescue breathing by giving two slow breaths.

Time 1 second per breath and watch chest rise and allow time for exhalation.

Volume enough to see the chest of the infant rise during ventilation.

CIRCULATION Assessment of

pulselessness: Brachial pulse (5-10 seconds)

Feel for the brachial pulse while maintaining head tilt with the other hand,

The brachial pulse is located on the inside of the upper arm, between elbow and shoulder.

If pulse is absent or below 60 per minute give 5 cycles of external 30 chest compressions followed by 2 slow breaths. Each breath over one second.

LAND MARK FOR EXTERNAL CHEST COMPRESSIONS

Nipple line technique. The area of compression is

just below the imaginary line, using the middle and ring fingers.

RATE OF COMPRESSION: 100 PER MINUTE

DEPTH OF COMPRESSION: 1/3-1/2 THE DEPTH FO THE CHEST

COMPRESSION / VENTILATION RATIO: 30:2

COMPRESSION / RELAXATION CYCLE SHOULD BE EQUAL

REASSESSMENT Reassess the infant after every 5 cycles of

30 compressions and 2 ventilations (2 minutes).

According to the findings: There is pulse and breathing, place the infant in

the recovery position, monitors vital signs until EMS arrives

There is pulse but no breathing continue rescue breathing one breath every 3-5 seconds (12-20 per minute) and reassess.

No pulse or breathing continue CPR 30:2. ratio, assess for pulse and breathing after 5 cycles (2minutes)

FOREIGN BODY AIRWAY OBSTRUCTION

CAUSES: Meat is common cause of obstruction Other food & foreign body may cause obstruction in

children and adults. Alcohol elevated blood level Elderly with dysphagia may be at risk

Air way obstruction may be Partial /Mild

Patient choking but able to cough, Low pitch sound during inhalation Gaseous exchange is normal

Treatment: Do not interfere at this stage. Encourage the victim to cough. If condition of the victim is worsening, immediately interfere.

Complete / severe- It can be mild gradually or severe from the start.

UNIVERSAL SIGN OF CHOKING The victim clutches his

neck with the thumb & index finger.

Inability to speak, inability to cough.

High pitched sounds or no sound during inhalation

Increased difficulty to breathe

Bluish skin color (cyanosis)

ADULT CONSCIOUS CHOKING VICTIMS Stand behind the adult/ child

victim. Try to release his/ her hands clutching the neck and wrap our arms around the waist. Head should be bent forward and slightly downward.

Apply the Heimlich maneuver as described below. Make a fist with one hand

and place the thumb side of the fist against the victim’s abdomen above the navel and well below the xiphoid process.

Grasp the fist with the other hand exert a series of inward upward thrusts until the foreign body is expelled, or the victim becomes unconscious.

CHEST THRUSTS FOR SPECIAL CASES Chest thrusts should

be used in the following conditions Advanced stages of

pregnancy Markedly obese victim

THE VICTIM BECOMES OR IS FOUND UNCONSCIOUS

If the victim with FBAO becomes unresponsive, the rescuer should carefully support the patient to the ground , immediately activate EMS , and then begin CPR. Each time the airway is opened during CPR, the rescuer should look for an object in the victim’s mouth and remove it.

INFANT FOREIGN BODY AIRWAY OBSTRUCTION

CONSCIOUS CHOKING INFANT Determine airway obstruction,

observe breathing difficulties. If breathing difficulty

increases or persists or breathing is absent perform back slaps and chest thrusts.

Hold the infant in a prone position, resting on your forearm. Support the infant’s head firmly by holding the jaw. The rescuer’s forearm should rest on / her thigh to support the infant. Deliver five back slaps forcefully between the infant’s shoulder blades, using the heel of the hand.

Cont. INFANT FOREIGN BODY AIRWAY OBSTRUCTION After delivering the back

slaps, turn the infant while the head and neck are firmly supported between your hands, with the head lower than trunk. Deliver up to 5 quick chest thrusts in the same location for infant’s CPR. The series of 5 back slaps and 5 chest thrusts should be continued until the foreign is expelled or infant becomes unconscious.

WHEN THE INFANT BECOMES OR FOUND UNCONSCIOUS

Call out “HELP” if others respond, activate the EMS system.

Position the infant: keep the infant face up. Immediately start CPR. For 5 cycles (2

minutes) then activate EMS if you are alone.

Each time the airway is opened during CPR, the rescuer should look for an object in the victim’s mouth and remove it.

USE OF BARRRIER DEVICES If breathing is not

present or is inadequate, begin rescue breathing by giving two slow ventilations using any available barrier device, e.g. Bag- valve-mask, pocket mask or face shield.

Be sure the proper size of mask to provide a good fitting to prevent leakage during ventilation.

HEALTH CARE PROFESSIONAL SHOULD NOT PERFORM MOUTH TO MOUTH BREATHING. THE USE OF A BARRIER DEVICE IS HIGHLY RECOMMENDED, E.G. FACE SHIELD, POCKET MASK OR BAG VALVE MASK.

AUTOMATED EXTERNAL DEFIBRILLATION (AED) AED is recommended to be used in adults and children 1 year of age

and older. Not recommended for infants below one year and neonates. Indications: unresponsiveness, absence of breathing, absence of

detectable pulse. Contra indications: responsiveness, presence of breathing,

presence of detectable pulse. For sudden witnessed collapse in adult and child, use the AED once it

is available. For un-witnessed cardiac arrest in the pre-hospital setting, use the

AED after 5 cycles of CPR (about 2 minutes) The AED machine must be able to accurately and reliably recognise

paediatric shockable rhythms and be capable of delivering energy dose.

Uses: for adult and children 1 year and above, anywhere, Health care provider who holds valid certificate in BLS. Most AEDs are equipped with small pads and means of reducing the

energy dose. If child pads/ system is not available, adult's pads/system can be

used but paediatric pads can not be used for adults.

Cont. AED Check for shockable rhythm only after completion

of 5 cycles of CPR If indicated for shocks deliver one single shock and

continue CPR. TYPE OF WAVEFORM:

Monophasic Shock 360 Joules biphasic truncated 150 – 200 Joules

No shock is indicated Check for pulse and breathing. If breathing is adequate,

place the victim carefully in the recovery position. If breathing and pulse not present, continue CPR. (Reassessment of patient is carried out if recovery was

not achieved. CPR to continue for 2 minutes, recheck for pulse and analyze for shockable rhythm and if required, single shock and CPR 5 cycles to be continued.)

DEFIBRILLATION It is the therapeutic use of kinetic energy in

the form of joules to be delivered to a chaotic rhythm in the heart known as ventricular fibrillation immediately using a proper defibrillator by qualified ACLS providers.

Physiologically the shock depolarizes the myocardium, terminating ventricular fibrillation or pulse less Ventricular tachycardia allowing normal sinus electrical activity to be restarted.

It is part of the chain of survival

Types of defibrillators A manual machine which necessitates the

presence of certified physician to diagnose and interpret the rhythm and properly use the defibrillator to shock the patient. It has two modes of delivering the shock: asynchronized defibrillation and synchronized cardioversion

AED has been introduced as an effective DC. It has only a synchronized mode of shock which allows paramedics, first responders, public at large trained, equipped with and authorized to use such a device in pre- hospital setting.

PRECAUTIONS

Wet person or wet conditions Excessive hair on the chest Moving vehicle Pacemaker and GTN patch In presence of inflammable

anaesthetics or concentrated oxygen