basiclifesupport2010

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 outcome
After review and study of these pages and attendance at an approved nursing skills lab the
critical 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)
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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. These
actions 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.
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3. The following changes in the BLS guidelines have been made to reflect the importance placed on
chest compression, particularly good quality compressions, and to attempt to reduce the number
and 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, the
CPR 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 cricoid
Airway & routinely recommended for use
rescuers were available, one pressure still allows for
Breathing with ventilations during
could apply cricoid pressure. aspiration. It is also difficult
cardiac arrest.
to properly train providers
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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 children
AED 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
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5. Steps Rationale
1. Check for danger ( safety) This ensures that the rescuer
operates in a safe environment
2. 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 regularly
3. 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 EMS
4. 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
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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.
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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! It's 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
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8. ventilations per minute) should be performed. important as chest
Technique 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.
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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 circulation
7. 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.
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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 victim's 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.
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11. If victim's chest does not rise with 1st rescue breathe, then before next
attempt
 Check victim's 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 exhausted
9. 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
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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 Mistakes
Rescue 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.
victim's mouth (and or nose( .
 Lifting hands off chest between compressions.
 Incorrect compression rate and /or ratio.
 Jerky or japping compressions.
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13. 13

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 Rationale
1. 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 alone
3. Assess need for CPR If the victim is unresponsive and not
breathing or only gasping
4. 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 needs
medical assistance
If you are alone and the child is breathing, leave the child to
phone the emergency response system, but return quickly and
recheck the child‟s condition frequently
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15. Allow the child with respiratory distress to remain in a position
that is most comfortable
 If the child is unresponsive, Most infants and children with cardiac arrest
Shout for help have an asphyxial rather than a VF arrest
2 minutes of CPR are recommended before the lone rescuer
activates the emergency response system and gets an AED if
one 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 CPR
6. Pulse Check ( trainer only) Start Chest Compressions
Take up to 10 seconds to attempt to feel for a pulse (brachial in
an infant and carotid or femoral in a child). During cardiac arrest, high-quality chest
 Inadequate Breathing with Pulse compressions generate blood flow to vital
If 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 breaths
per minute (1 breath every 3 to 5 seconds) until spontaneous Hands-Only (Compression-Only) CPR
breathing resumes Optimal CPR in infants and children includes
Reassess the pulse about every 2 minutes but spend no more both compressions and ventilations, but
than 10 seconds doing so compressions alone are preferable to no CPR
 Bradycardia with Poor Perfusion
If the pulse is 60 per minute and there are signs of poor
perfusion (i.e., pallor, mottling, and cyanosis) despite support
of 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 surface
For an infant, lone rescuers
Should compress the sternum with 2 fingers placed just below
the intermammary line
Do not compress over the xiphoid or ribs. Rescuers should
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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 is
CPR is provided by 2 rescuers. Encircle the infant‟s chest with preferred over the 2 finger technique because
both hands; spread your fingers around the thorax, and place it produces higher coronary artery perfusion
your thumbs together over the lower third of the sternum. pressure, results more consistently in
Forcefully compress the sternum with your thumbs. appropriate depth or force of compression and
may generate higher systolic and diastolic
pressures
For a child,
Compress the lower half of the sternum at least one third of the
AP 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 the
ribs.
After each compression, allow the chest to recoil completely
7. Open the Airway and Give Ventilations
Open the airway using a head tilt– chin lift maneuver for both In an unresponsive infant or child, the tongue
injured and non injured victims To give breaths to an infant, use may obstruct the airway and interfere with
a mouth-to-mouth-and nose technique. ventilations.
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17. To give breaths to a child, use a mouth-to mouth technique.
Each breath should take about 1 second. If the chest does not
rise, reposition the head, make a better seal, and try again
Bag-Mask Ventilation (Healthcare Providers) not
recommended for a lone rescuer during CPR Bag-mask ventilation requires training and
Use 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 the
an effective tidal volume or the longer inspiratory times airway, making a tight seal between the mask
required by full-term neonates and infants and face, delivering effective ventilation, and
In older children or adolescents, an adult self-inflating bag assessing the effectiveness of that ventilation.
(1000 mL) may be needed to reliably achieve chest rise
Attach self-inflating bag to o2 source by 10-15 ml to deliver
oxygen concentration 60%-80 %
Effective bag-mask ventilation requires a tight seal between the
mask and the victim‟s face. Open the airway by lifting the jaw
toward the mask making a tight seal and squeeze the bag until
the chest rises
8. Coordinate Chest Compressions and Breathing
(The ideal compression-to-ventilation ratio in infants and
children is unknown.)
For 2-rescuer infant and child CPR, one provider should
perform chest compressions while the other keeps the airway
open and performs ventilations at a ratio of 15:2. Deliver
ventilations with minimal interruptions in chest compressions
The ventilation rescuer delivers 8 to 10 breaths per minute (a
breath every 6 to 8 seconds), being careful to avoid excessive
ventilation in the stressful environment of a pediatric arrest.
The lone rescuer should continue this cycle of 30 compressions
and 2 breaths for approximately 2 minutes (about 5 cycles)
before leaving the victim to activate the emergency response
system and obtain an automated external defibrillator (AED) if
one is nearby.
9. Defibrillation VF can be the cause of sudden collapse or
For 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 collapse
required, it should be doubled to 4 J/kg. (e.g., a child collapsing during an athletic
event) are likely to have VF or pulseless VT
If a manual defibrillator is not available, an AED equipped with and need immediate CPR and rapid
a pediatric attenuator is preferred for infants and children 8 year defibrillation. VF and pulseless VT are
of age. If neither is available, an AED without a dose attenuator referred to as “shockable rhythms” because
may be used they respond to electric shocks
(defibrillation).
The AED will prompt the rescuer to re-analyze the rhythm
about every 2 minutes. Shock delivery should ideally occur as
soon as possible after compressions.
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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
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19. Post-Procedure Complications
1. Regurgitation during CPR
Regurgitation 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 can
further 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) distension
Causes:-
 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 injuries
Types:-
 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 victim's rib.
 Press straight down.
 Give smooth, regular and uninterrupted compression.
 Avoid pressing chest too deeply.
4. Dentures, loose or broken teeth, or dental appliances
Prevention:-
 Leave tight fitting dentures in place.
 Remove loose or broken teeth, dentures, and/or dental appliances.
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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 CPR
unresponsiveness;
call 123, get AED
Unresponsive (for all ages)
No breathing or no
Recognition 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-B
Open airway Head tilt – chin lift(HCP suspected trauma: jaw thrust)
Pulse check Carotid Brachial
Start chest compressions If no normal breathing or pulse
Lower half of sternum
Compression 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 inches
Compression 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 compressions
Chest wall recoil
HCPs rotate compressors every 2 minutes
Compression: ventilation 30:2 Single rescuer
30:2 (1 or 2 rescuers)
ratio 15:2 two HCP rescuers
Compression Minimize interruptions in chest compressions
interruptions Attempt to limit interruptions to <10 seconds
Two breaths at one second per breath. Should not interrupt chest
Breathing
compressions for more than six seconds to perform the two breaths.
Ventilations: when rescuer
untrained or trained and Compressions only
not proficient
1 breath every 6-8 seconds (8-10 breaths/min)
Ventilations with
Asynchronous with chest compressions
advanced
About 1 second per breath
airway (HCP)
Visible chest rise
Attach and use AED as soon as available. Minimize interruptions in
Defibrillation chest compressions before and after shock;
resume CPR beginning with compressions immediately after each shock
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21. Automated External Defibrillator (AED) USE
AEDs are sophisticated, reliable, safe, computerized devices that deliver electric shocks to
victims of cardiac arrest when the ECG rhythm is one that is likely to respond to a shock.
Types of automated external defibrillator
All 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 fully
automatic AED administers the shock without the need for intervention by the operator. Some
semi-automatic AEDs have the facility to enable the operator (normally a healthcare
professional) to override the device and deliver a shock manually, independently of prompts.
Sequence of actions
1. Follow the adult BLS sequence. Do not delay starting CPR unless the AED is
available 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
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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 compression
4. 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
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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 AEDs
Provide 5 cycles of CPR, 30 compression to 2 breaths, for 2 minutes before using an AED on a
child 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, that
attenuate the current delivered during defibrillation, should be used in children aged between 1
and 8 years if they are available; if not, standard adult-sized pads should be used. The use of an
AED is not recommended in children aged less than 1 year. However, if an AED is the only
defibrillator available its use should be considered.
Defibrillation if the victim is wet
As 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 a
shock. Dry the victim‟s chest so that the adhesive AED pads will stick and take particular care to
ensure that no one is touching the victim when a shock is delivered.
Voice prompts
The sequence of actions and voice prompts provided by an AED are usually programmable and
it 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 people
working nearby. In a complementary strategy, first responders are dispatched by an ambulance
control 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 a
patient has been associated with more modest success rates. However, this strategy does enable
treatment of people who arrest at home, the commonest place for cardiac arrest to occur.
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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 successful
outcome, it is important not to confuse this emergency with fainting, heart attack, seizure, or
other 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 are
summarized in the table below. It is important to ask the conscious victim „Are you choking?‟
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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.
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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).
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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 the
upper 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 should
therefore be referred for an immediate medical opinion.
Choking While Alone
If you choke while you are alone, use your fists to do thrusts on yourself. Or lean over the back
of a chair and press hard to pop out the object.
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28. Baby (Younger Than 1 Year)
FBAO may cause mild or severe airway obstruction. When the airway obstruction is mild, the
child can cough and make some sounds. When the airway obstruction is severe, the victim
cannot 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 123
If a baby can't breathe, cough, or make sounds, then:
 Put the baby face down on your forearm so the baby's head is lower than his or her chest.
 Support the baby's head in your palm, against your thigh. Don't cover the baby's mouth or twist
his or her neck.
 Use the heel of one hand to give up to 5 back slaps between the baby's shoulder blades.
 If the object does not pop out, support the baby's head and turn him or her face up on your thigh.
Keep the baby's head lower than his or her body.
 Place 2 or 3 fingers just below the nipple line on the baby's 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.
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29.  If the baby faints, call 123(if you haven't 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.
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