Chapter 8.docx

Basic Life Support (BLS) Resuscitation Skills Chapter 8 Basic Life Support for Healthcare Providers High quality CPR includes an uninterrupted compression rate of 100-120 per minute, appropriate compression depth based on the age of the casualty and allowing for complete chest recoil after each comp...

Basic Life Support (BLS) Resuscitation Skills Chapter 8 Basic Life Support for Healthcare Providers High quality CPR includes an uninterrupted compression rate of 100-120 per minute, appropriate compression depth based on the age of the casualty and allowing for complete chest recoil after each compression. It is important to remember that where local protocols (including legislation, medical direction and professional/workplace requirements) differ from this information, the local protocol supersedes information in this chapter. Age categories for resuscitation The health care provider will respond to casualties based on the following categories: Adult-onset of puberty and older Child-1 year of age to the onset of puberty (about 12 to 14 years, as defined by the presence of secondary sex characteristics) Infant-anyone under the age of 1 year Neonate/newborn-an infant who has been delivered, and in the first hours after birth and until they leave the hospital. The health care provider will not need to differentiate this group from other infants, unless they are specifically trained to provide resuscitative care for that age group. Activation of emergency medical response system Health care providers should be familiar with when and how to activate their own internal and/or external Emergency Medical Response system. A plan should be in place to allow for an AED to arrive on scene with the rescuer, or for an AED to be quickly retrieved and easily accessible. Casualties of all age-two rescuers Anytime two rescuers are present, one rescuer should stay and begin CPR while the second rescuer will activate the Emergency Medical Response System and obtain an AED, if one is not already present. Adult casualty-lone rescuer Anyone in cardiac arrest will need CPR, defibrillation and Advanced Life Support. The lone rescuer should activate the Emergency Medical Response System immediately when they encounter a witnessed arrest or an unwitnessed unresponsive adult casualty. When a casualty of any age is believed to have suffered an asphyxia! arrest, the lone rescuer should call for help using a mobile phone. The phone can be put on speaker phone to save time. If a mobile device is not present, the rescuer should provide two minutes of CPR before leaving to activate EMS and obtaining the AED. The objective is to correct the cause of the arrest, the lack of oxygen, by performing two minutes of CPR first. Infant and child casualty-lone rescuer When the lone rescuer witnesses a child or infant casualty who suddenly collapses they should immediately activate their Emergency Medical Response System and obtain and use the AED right away. In the case of an unwitnessed casualty, if they cannot activate the Emergency Medical Response System from the scene, the lone rescuer should provide two minutes of CPR before leaving to caII. When activating the Emergency Medical Response System, the rescuer may consider carrying the infant/child if the casualty is small enough, if injuries permit and if the distance they must go does not impact on the start or resumption of CPR. Artificial respiration Artificial respiration (AR) is a way you can supply air to the lungs of a casualty who is breathing ineffectively or not breathing at all but has an adequate pulse. Pulse/breathing checks should be performed every two minutes for at least 5 seconds but no longer than 10 seconds. The methods for ventilating a non-breathing casualty are: Mouth-to-mask with supplemental oxygen Two person bag-valve mask Infants and children with a pulse rate of less than 60 beats per minute and who show signs of poor perfusion despite oxygen and ventilation should receive chest compressions in addition to ventilations. Artificial respiration can be given in a wide range of situations. In an emergency situation, keep the following in mind: You can start AR right away in any position (but it is best if the casualty is on their back on a firm, flat surface) You can continue AR while the casualty is being moved to safety by other rescuers You can give AR for a long time without getting too tired AR techniques can be used to help a casualty with severe breathing difficulties Giving AR in some situations may be more difficult than in others. Some examples are: When severe injuries to the mouth and nose prevent a good seal around the mouth When blood and/or other body fluids drain into the throat and block the airway, do your best to drain the mouth prior to beginning AR The casualty has been poisoned by a toxic gas-like hydrogen sulphide and coming in contact with the casualty may result in you being poisoned The casualty has a corrosive poison on the face or in the mouth, and you don't have a face mask When this happens, you have to do the best you can (based on your level of training) without putting yourself into danger. Opening the airway Health care providers will primarily open a casualty's airway using the head-tilt chin-lift, except in cases where a spinal injury is suspected. In those cases, a jaw thrust is used. In the event that a spinal injury is suspected and the jaw thrust does not work, use a head-tilt chin-lift to open the airway. Using a jaw thrust With the head and neck supported, position your hands on either side of the head. Steady your thumbs on the cheek bones. Grasp the angle of the jaw with the middle, ring and little fingers and lift to open the airway. If necessary, open the mouth using the index fingers. Check for signs of breathing and pulse for at least 5 and up to 10 seconds while holding the airway open with the jaw thrust. If there is a pulse, but no breathing, position the mask over the casualty's face. Blow into the casualty's mouth and watch for the chest to rise. Keep lifting the jaw to hold the airway open. If there is no pulse, begin compressions and continue CPR until an AED arrives on scene. Bag-valve mask (BVM) A bag-valve mask is a self-inflating bag with a one-way valve that a face mask can be attached to. The BVM will also accept an oxygen reservoir bag. The bags come in three sizes: adult, child, and infant. Using a bag-valve mask After opening and securing the airway, select the correct mask size, based on the size of the casualty (adult, infant, or child). Position your thumbs over the top half of the mask with your index and middle fingers over the bottom half Place the apex of the mask over the bridge of the nose, then lower the mask over the mouth and chin. If the mask has a large round cuff surrounding a ventilation port, centre the port over the mouth Use your ring and little fingers to bring the jaw up to the mask Instruct a second rescuer to squeeze the bag with two hands, providing only enough air to make the chest rise Using advanced airways with masks When using a pocket or bag valve mask, using an advanced airway is recommended. This involves advanced skill training. If an advanced airway is not available or you are not trained on how to use it, this does not preclude you from using a pocket mask or BVM. Using one or the other without an airway is acceptable. The health care professional may be asked to assist with the bag valve mask when an advanced responder has inserted an advanced airway. Adjunct airways (oral or nasal) may be necessary in conjunction with bag-valve mask if the casualty is unresponsive Adult & child artificial respiration Two-rescuer BVM One rescuer positions themselves at the casualty's head, and places the mask on the face. Using the thumb and first finger of EACH hand around the valve in a "C" position they press the mask against the face. Using the remaining fingers of EACH hand in an "E" position they lift up on the jaw and Tilt the head back to open the airway. If the casualty has a suspected head/spinal injury, use a jaw thrust. The second rescuer will squeeze the bag to ventilate. Give each breath in 1 second. Make the chest visibly rise. Adult rescue breathing: 1 breath every 5-6 sec. Child rescue breathing: 1 breath every 3-5 sec. Check the pulse approximately every 2 minutes. Infant artificial respiration Two rescuer BVM One rescuer positions themselves at the casualty's head and places the mask over the nose and mouth. Do not cover the eyes or chin. Using the thumb and first finger of EACH hand around the valve in a "C" position they press the mask against the face. Using the remaining fingers of EACH hand in an "E" position they lift up on the jaw and tilt the head back to open the airway. If the casualty has a suspected head/spinal injury, use a jaw thrust. The second rescuer will squeeze the bag to ventilate. Give each breath in 1 second. Make the chest visibly rise. Give 1 breath every 3-5 seconds (12-20 per minute). Check the pulse approximately every 2 minutes. Assisted breathing Assisted breathing helps a casualty with severe breathing difficulties to breathe more effectively. In a clinical setting you may have access to a CPAP (continuous positive airway pressure) machine. It is most useful when the casualty shows very little or no breathing effort. If breathing effort is good, the casualty will likely breathe better on their own. Start assisted breathing when you recognize the signs of severe breathing difficulties. The technique for assisted breathing is the same as for artificial respiration except for the timing of the ventilations. If the casualty is breathing too slowly, give a breath each time the casualty inhales, plus an extra breath in between the casualty's own breaths. Give one breath every five seconds for a total of 12 to 15 breaths per minute. If the casualty is breathing too fast, give one breath on every second inhalation by the casualty. This will hopefully slow down the casualty's own breathing. Give a total of 12 to 15 breaths per minute. If the casualty is conscious, explain what you are going to do and why. Reassure the casualty often and encourage them to try to breathe at a good rate with good depth. Artificial respiration to someone who breathes through the neck Some people breathe through an opening at the base of the neck. This opening, called a stoma, is the result of a previous medical operation called a laryngectomy. You may not know a person breathes through the neck when you try to give AR. If the air seems to go down the airway when you blow, but the chest doesn't rise, check the neck for a stoma. You may also hear air coming out of the stoma as you blow. Giving AR to a casualty with a Stoma The first aid rescue sequence does not change. Once you recognize a person breathes through a stoma, do the following: Expose the entire neck and remove all coverings over the stoma. If there is a tube coming out of the stoma, don't remove it Put a pad under the shoulders to keep them slightly elevated (if you have one close by) Keep the head in line with the body and keep the chin raised Seal the mouth and nose with the hand closest to the head Seal your face shield or your pocket mask over the stoma, or connect your BVM to the tracheostomy tube, and ventilate Watch the chest rise (look, listen and feel for air movement) Let the air escape from the stoma between breaths Maintain a clean air passage, using a cloth to clean the opening; never use paper tissues Gastric distension If you blow into a casualty too fast or too hard, air may be bypassed into the stomach causing it to fill with air and become bloated. This is called gastric distension, and it can make it harder to ventilate the casualty and increase the chances that the casualty will vomit. If the stomach becomes distended, try to prevent further distension by: Repositioning the head and opening the airway again Blowing more slowly, with less air Making sure the airway is held fully open It is unusual, but the stomach can become so distended that the lungs cannot expand. In this case, the air you blow won't go into the lungs, so you have to relieve the gastric distension by forcing the air in the stomach out. Only relieve gastric distension when the lungs cannot expand and AR is ineffective. To prevent gastric distension Give breaths at the recommended rate Only blow enough air to make the chest rise Make sure the airway is fully open-keep the head tilted welI back (but not over-extended) Cardiopulmonary resuscitation (CPR) When assessing the casualty, the HCP will check for breathing and a pulse simultaneously before beginning compressions. Rescuers should check the: Adult-carotid pulse Child-carotid or femoral pulse Infant-brachia! or femoral pulse Brachycardia (slow pulse rate) Any casualty with a pulse rate of less than 60 beats per minute and showing signs of poor perfusion/circulation, despite oxygen and ventilation, should also receive chest compressions. The low heart rate (<60 bpm) does not provide enough circulation to sustain adequate cellular oxygenation; by providing a compression rate of 100 to120 compressions per minute the health care provider will assist in providing adequate circulation to a casualty. CPR (compression and ventilation) rates Health care providers will provide the same compression to ventilation rates as the lay rescuer when performing one rescuer CPR for adults, children and infants; as well as two-rescuer adult, but the ratio will change when they perform two-rescuer CPR for the child and infant. For two-rescuer CPR on a child or infant, the rescuer will provide compressions and ventilations at a ratio of 15 compressions to 2 ventilations. Depth of compressions should be at least 1/3 the depth of the infant or child's chest with a rate of 100 to 120 compressions per minute. In the case of the infant casualty, the rescuer may encircle the infant casualty's chest and use their thumbs side-by-side or one on top of the other to provide compressions. The method used will depend on the size of the infant casualty and the rescuer's thumbs. Adult CPR/AED Check breathing and pulse for at least 5 and no more than 10 seconds. If there is a pulse, but no breathing, begin artificial respiration. If there is no pulse and no breathing, or only agonal breaths, begin compressions. Agonal breathing is an abnormal pattern of breathing driven by a brain-stem reflex, characterized by irregular gasping respirations at times accompanied by strange vocalizations. They can occur with cardiac arrest and lead bystanders to believe the casualty is breathing. One rescuer 30:2 Give 30 chest compressions in the middle of the upper chest using two hands. Push hard, push fast (100 to 120 per min) to a depth of 5-6 cm (2-2.4 inches). The pressure and release phases take the same time. Release pressure and completely remove your weight at the top of each compression to allow chest to return to the resting position after each compression. Minimize interruptions. Give 2 breaths. Continue 30:2 until: An AED is ready for use EMS/advanced providers arrive or The casualty shows signs of recovery. Two or more rescuers 30:2 Rescuer one-30 chest compressions at a rate of 100 to 120 per minute. Rescuer two-give 2 rescue breaths, enough to make the chest visibly rise. Minimize interruptions. Quickly change positions every 5 cycles (2 minutes). If an advanced airway is in place-one breath every 6-8 seconds with no pause in compressions for breaths. DefibriIlation Expose the chest. Turn on the AED. Follow the voice prompts. Select and attach the adult pads. SHOCK advised-CLEAR and give 1 shock. Immediately resume chest compressions. NO SHOCK advised-immediately resume chest compressions. Continue 30 compressions-2 breaths for 5 cycles (approximately 2 minutes). Analyze heart rhythm, continue CPR/AED until advanced providers take over. Child CPR/AED One rescuer 30:2 Give 30 chest compressions in the middle of the upper chest using one or two hands. Push hard, push fast (100 to 120 per min) to a depth of about 2 inches (5 cm), or about 1/3 of the depth of the chest. The pressure and release phases take the same time. Release pressure and completely remove your weight at the top of each compression to allow chest to return to the resting position after each compression. Minimize interruptions Give 2 breaths. Continue 30 compressions: 2 breaths. Two or more rescuers 15:2 Rescuer one-15 chest compressions at a rate of at least 100 to 120 per minute. Rescuer two-give 2 rescue breaths, enough to make the chest visibly rise. Quickly change positions every 10 cycles (2 minutes). If an advanced airway is in place-one breath every 6-8 seconds with no pause in compressions. DefibriIlation Expose the chest. Turn on the AED. Follow the voice prompts. Select and attach the pediatric pads. If pediatric pads are not available, use adult pads. SHOCK advised: CLEAR and give 1 shock. Immediately resume chest compressions. NO SHOCK advised: Immediately resume chest compressions. Continue 15 compressions-2 breaths for 5 cycles (approximately 2 minutes). Analyze heart rhythm, continue CPR/AED until advanced providers take over. Infant CPR/AED In the case of the infant casualty, the rescuer may encircle the infant casualty's chest and use their thumbs side-by-side or one on top of the other to provide compressions. The method used will depend on the size of the infant casualty and the rescuer's thumbs. One rescuer 30:2 Give 30 chest compressions just below the nipple line using two fingers. Push hard, push fast (100 to 120 per minute) to a depth of about 1 1/2 inches (4 cm) or 1/3 of the depth of the chest. The pressure and release phases take the same time. Release pressure and completely remove your weight at the top of each compression to allow chest to return to the resting position after each compression. Minimize interruptions. Give 2 breaths. Continue 30 compressions: 2 breaths. Two or more rescuers 15:2 Rescuer one-15 chest compressions at a rate of at least 100 to 120 per minute. Rescuer two-give 2 rescue breaths, enough to make the chest visibly rise. Quickly change positions every 10 cycles (2 minutes). If an advanced airway is in place-one breath every 6-8 seconds with no pause in compressions. Defibrillation Expose the chest. Turn on the AED. Follow the voice prompts. Select and attach the pediatric pads. If pediatric pads are not available, use adult pads. SHOCK advised: CLEAR and give 1 shock. Immediately resume chest compressions. NO SHOCK advised: Immediately resume chest compressions. Continue 15 compressions-2 breaths for 5 cycles (approximately 2 minutes). Analyze heart rhythm, continue CPR/AED until advanced providers take over. Team approach Health care providers should practice working in integrated teams. When a team is available, one rescuer provides airway control and ventilations right away, a second rescuer begins compressions and a third obtains and uses the AED. This is the optimal situation as the rescuers have the ability to maximize the compression fraction of CPR prior to defibrillation. A high performance team can achieve compression fractions of 80%, i.e. perform effective chest compression for the majority of the time they are resuscitating the casualty.