Pakistan Air Force Emergency Medical Services Procedures PDF

EMERGENCY MEDICAL SERVICES ACAS (MS) SECTT AIR HEADQUARTERS, PESHAWAR RESTRICTED  RESTRICTED IDENTIFICATION OF PARTICIPANTS 1. PATRON IN CHIEF AIR CDRE QAMAR HASNAIN ACAS (MS) 2. DEPUTY PATRON GP CAP...

EMERGENCY MEDICAL SERVICES ACAS (MS) SECTT AIR HEADQUARTERS, PESHAWAR RESTRICTED  RESTRICTED IDENTIFICATION OF PARTICIPANTS 1. PATRON IN CHIEF AIR CDRE QAMAR HASNAIN ACAS (MS) 2. DEPUTY PATRON GP CAPT SHAHAMAD ALI DIRECTOR ATH / CFS 3. SUPERVISED BY WG CDR TAUSIF HAIDER ASSISTANT DIRECTOR TRAINING 4. COMPILED BY SNR TECH ABID KHAN (PTA) COMBAT MEDIC SPLT (USA) 5. PROOF READING WG CDR M TARIQUE HoD MEDICINE WG CDR MOIZZA AZIZ HoD GYNAE&OBS SQN LDR MARYAM RAFIQ HoD PAEDS SQN LDR SIDRA ABDULLAH CL SURG SPLT SQN LDR ARSHAD UL GHAFOOR GRADED ANESTHETIST SQN LDR JAVERIA MASOOD 2 I/C PAF HOSP MUSHAF 6. COMPOSED BY WRT OFF MASOOD ALAM MED ASSTT (G) WO I/C TRAINING CMA MUHAMMAD ADNAN MED ASSTT (G) I/C TRAINING 7. PRINT BY RESTRICTED  RESTRICTED CHAPTER CONTENTS PAGE NO NO 1. EMERGENCY MEDICAL SERVICES (a) Learning Objectives 1 (b) Introduction 1 (c) Activating EMS 1 (d) Stage 1: 1122 Call Receptions 3 (e) Stage 2: Ambulance Services Activation 4 (f) Stage 3: On Site Care 4 (g) Stage 4: Safe Transportation 4 (h) Stage 5: Definitive Care at Hospital 4 2. RESUSCITATION – ABC (a) Learning Objectives 5 (b) Introduction 5 (c) Before Beginning Resuscitation 5 (d) Assessing the Patient 6 (e) Positioning the Patient 10 (f) Opening the Airway 10 (g) Airway Adjuncts 12 (h) Initial Ventilations and Pulse Check 16 (j) Recovery Position 19 (k) Providing Chest Compressions (Adult CPR) 19 (l) Infant CPR 23 (m) Special Considerations 26 (n) When Not to Begin or to Terminate CPR 28 (o) Train Healthcare provider vs Lay Provider 29 (p) AED & ECG 30 (q) ECG 33 (q) Post Cardiac Arrest Care 35 3. AIRWAY OBSTRUCTION (a) Learning Objectives 37 (b) Introduction 37 (c) Clearing-Airway Obstructions 37 (d) Mild Airway Obstruction 37 (e) Severe Airway Obstruction 38 (f) Abdominal Thrusts 38 (g) Chest Thrusts 39 (h) Back Blows 39 (j) Airway Clearance Sequences 40 (k) Procedures for a Child or Infant 40 RESTRICTED  RESTRICTED 4. FIRST AID IN SPECIAL SITUATIONS (a) Learning Objectives 43 (b) Introduction 43 (c) DRABCD 43 (d) Allergic Reaction (Anaphylaxis) 44 (e) Bleeding 45 (f) Burns & Scalds 47 (g) Electric Shock 50 (h) Epileptic Seizure 51 (j) Eye Injuries 54 (k) Fractures & Dislocations 55 (l) Heart Attack 57 (m) Heat- Induced Conditions 58 (n) Drowning 60 (o) Poisoning 61 (p) Shock 62 (q) Snake Bite 64 (r) Spinal Injury 66 (s) Sprains & Strains 67 (t) Stroke 68 (w) Transport of Critically Ill Patients 68 5. MEDICAL EQUIPMENT AT CARDIAC AMBULANCE (a) Learning Objectives 70 (b) Introduction 70 (c) Stretcher Trolley (Auto Loading) 71 (d) Stretcher (Scoop) 72 (e) Spinal Board & Head Immobilizer 73 (f) AMBU Bag (03 Different sizes) 76 (g) Oxygen Cylinder with Flow meter & Regulator 78 (h) Sphygmomanometer Aneroid 79 (j) Thermometer 80 (k) Glucometer 81 (l) Multiparameter Monitor 82 (m) Suction Unit Portable 83 (n) Nebulizer 84 (o) Infusion Pump & Syringe Pump 86 (p) AED 87 (q) Ventilator Portable 88 (r) Scale of Equipment for Cardiac/FSIR/Normal Ambulance 91 RESTRICTED  RESTRICTED AND IF ANY ONE SAVED A LIFE, IT WOULD BE AS IF HE SAVED THE LIFE OF THE WHOLE PEOPLE. “AL-QURAN” RESTRICTED  RESTRICTED FOREWORD When a person is injured or becomes ill, it rarely happens in a hospital with doctors and Nurses standing by. In fact some time, usually passes between the onset of the injury or illness and the patient’s arrival at the hospital. To safe this time, Emergency Medical Services (EMS) system has been developed to provide pre-hospital care, stabilization for serious illness and injuries and transport to definitive care. Training and qualification of personal involved in Emergency Medical Services vary widely throughout the world. In PAF, dedicated Emergency Medical Services are available round the clock to render its support. This manual provides base line information for effective training of all health care workers, especially staff detailed at Accident & Emergency departments and at EMS services. Reference literature in preparation of this manual are: Basic Life Support - Red Cross Association latest edition Emergency Care, Daniel Limmer 14th edition (USA EMT syllabus book) First Aid Booklet of ACAS (MS) Sectt RESTRICTED  RESTRICTED CHAPTER 1 EMERGENCY MEDICAL SERVICES AN INTRODUCTION Learning Objectives 1. As under: (a) To produce confident, adaptive inquisitive EMS handlers. (b) To achieve core competencies required to successfully practice emergency situations. (c) To provide safe and effective patient care during emergency situations. (d) To document responses and be able to audit them and apply course corrections for improvement. Introduction 2. Pre hospital care is an essential part of medical care that happens before the patient reaches a healthcare faiclity. It could be at home, office or road side. PAF medical services, primarily, are static facilites. However, to manage this aspect, 1122 system has been integrated in all medical setups. These setups are manned and function through augmentation from existing resources and all respective OsC Hosps and SMOs take keen interest in these aspects. This precis focuses of provision of best possbile medical care by first responders. However, the principles of care, whether pre-hospital or within hospital, shall stay the same. 3. Emergency medical services, also known as ambulance services or paramedic services are emergency services that provide urgent pre-hospital treatment and stabilization for serious illness and injuries and transport to definitive care. EMS has two phases, pre hospital care (onsite care and safe transportation) and hospital care (definitive early care). Activating EMS 4. In case of any emergent situation responsibility lies over any person present at situation. If there are multiple individuals and assistance is available, the other person should call 1122 or otherwise activate the EMS system as soon as a patient collapses or is discovered in collapse. 1 RESTRICTED  RESTRICTED 5. If there is one person, alone at site, He / She will have to determine whether to activate EMS immediately or to initiate 2 minutes of resuscitation before EMS activation. In most cases, 2 minutes of resuscitation before activating EMS is recommended for children and infants, but immediate activation of EMS is recommended for adults. However, there are some instances mentioned below that indicate a different approach: (a) With an adult, first determine unresponsiveness, pulse, and breathing (will describe later), and activate EMS before returning to the patient to initiate the next steps. Cardiac arrest in an adult is likely to be the result of a disturbance of the heart's electrical activity that will require defibrillation, so getting defibrillation equipment to the patient takes precedence over starting CPR. When cardiac arrest is probably not the result of a disturbance of the heart's electrical activity, however (e.g., injury, or drug overdose), it is more important to perform rescue breathing, so you would perform CPR briefly before activating EMS. (b) If the patient is a child or an infant, perform 2 minutes of resuscitation before activating EMS. Children and infants generally have healthy hearts, and cardiac arrest in these patients is likely to have resulted from respiratory arrest. In this situation, rescue breathing is more likely to be helpful, and defibrillation is less likely to help. If the child has heart disease, however, cardiac arrest is more like that of an adult. In this instance, calling for a defibrillator is more important than performing rescue breathing. (c) So generally, for children and infants, perform 2 minutes of resuscitation before activating EMS, and for adults activate EMS before performing rescue breathing. 2. safe 3. Early Definative 1. On Site Care Transportation Care Pre Hospital Hospital 6. To handle Medical emergency array of expertise are required. Synchronization of EMS staff plays vital role to have an efficient system. 2 RESTRICTED  RESTRICTED Schematics of different levels of EMS services 2. Ambulance 1. 1122 Call 2 Services 3. On Site Care Reception Activation 1 5. Definative 4. Safe Care at Hospital Transportation Depicts vitally important decisional step 1. Active listening is needed (get maximum details regarding status/ condition of patient and location) & Timely dispatch of worthy ambulance with needed HR on board 2. Identify health hazard and start actions accordingly. Stage 1: 1122 Call Receptions 7. Dedicated phone line 1122 is being established. Designated person responsible to attend EMS related calls. Availability of check sheet at EMS desk and proper endorsement of particulars in a special register. Time of Call __________________________________ Date of call ___________________________________ Name of person called ___________________________ Contact number of person who has requested EMS response ___________________ Nature of Emergency __________________________________________________ Approximate age and gender of person requires EMS _________________________ Name and details of Person for whom EMS are required _______________________ Address EMS response is needed ________________________________________ Name to DMO ________________________________________________________ 3 RESTRICTED  RESTRICTED Time EMS dispatched __________________________________________________ Name of Driver _______________________________________________________ Names of EMS team member’s __________________________________________ Practical: Conduct training by simulating emergency call at reception and extracting required information. INSTRUCTION: Record keeping: Format of desired information will be finalized locally and record will be kept available with MOIC A&E/MI Room/SMO Stage 2: Ambulance Services Activation 8. DMO & NCO EMS is responsible to pass information and generate required response based upon information received about causality. Stage 3: On Site Care 9. EMS team leader is responsible to execute best course of action. All measures adopted will be documented on return to hospital and audit of response will be conducted by MOIC MI Room/A&E/SMO and apply course correction based upon this information. Ideal desired response from EMS is goal to achieve. Stage 4: Safe Transportation 10. During this phase important information about causality and ETA to be passed to DMO/ NCO EMS. Stage 5: Definitive Care at Hospital 11. Practical exercises will be conducted vigorously so that all attendees of course can handle following aspects professionally: (a) ABC - Assessment and all relevant procedures. (b) CPR (c) Patient shifting (d) Stature loading unloading ambulance INSTRUCTION: Record keeping: Respective DMO/MOIC will ensure to endorse in daily DMO BOOK related to Details of EMS response generated and fortnightly these responses will be audited and weakness will be ascertained and course corrective measures will be adopted, course correction adopted will also be endorsed, register is to be counter signed by SMO / OC / Snr Flt Surg. 4 RESTRICTED  RESTRICTED CHAPTER 02 RESUSCITATION - ABC Learning Objectives 1. As Under: (a) All participants shall be able to perform effective CPR independently. (b) All participants shall be able to apply correct techniques related to resuscitation including Assessment of patient, Airway maintenance, CPR, Use of ECG and AED. Introduction 2. When a patient's breathing and heartbeat is stop, clinical death occurs. This condition may be reversible through CPR and treatments. However, when the brain cells die, biological death occurs. This usually happens within 10 minutes of clinical death, and it is not reversible. In fact, brain cells will begin die after 4 to 6 minutes without fresh oxygen supplied from air breathed in and carried to the brain by circulating blood. Cardio Pulmonary resuscitation (CPR) consists of the actions you take to revive a person—or at least temporarily prevent biological death-by keeping the person's heart and lungs working. Before Beginning Resuscitation 3. An essential element of success in any resuscitation effort is teamwork. Rescuers perform many tasks during a resuscitation effort, and to be successful, they must work together in a coordinated, organized, and efficient manner. Many of these tasks are time sensitive and quite specific in how they must be performed, so working together is vital. This is especially true because many things happen simultaneously when the resuscitation effort is proceeding well. A team leader must be knowledgeable about resuscitation techniques, skilled in patient assessment, and clear in his or her directions to the team. Communication among members of the team must be accurate and timely to give the patient the best chance of revival. 5 RESTRICTED  RESTRICTED 4. Another element of successful resuscitation efforts is the ability to tailor the approach to the patient based on the circumstances. A patient who was submerged under water will receive the same general sequence of assessment steps as a patient who suddenly collapsed at home, but the specifics of treatment may be quite different. A good team adapts its approach to the apparent cause of a cardiac arrest. Table A-I lists the initial steps in basic life support resuscitation, including assessing the patient, activating EMS, positioning the patient, and ensuring an open airway. Assessing the Patient 5. Patient assessment is crucial. Initiate resuscitation after determining that the patient needs it. The required assessments are often described as determining unresponsiveness, breathlessness, and Pulselessness—or the ABCs (airway, breathing, and circulation), As Table A-I show, these categories overlap, and treatment might not occur in A-B-C sequence. For example, a patient in cardiac arrest should receive chest compressions before rescue breaths (i.e., C-A-B sequence). Determining Unresponsiveness 6. When a patient has collapsed, first action is to determine responsiveness. Tap or gently shake the patient (being careful not to move a patient with possible spinal injury) and shout "Are you 0K?" The patient who is able to respond does not require cardiopulmonary resuscitation. 6 RESTRICTED  RESTRICTED 7. If the adult patient is unresponsive, immediately activate EMS unless the patient's condition is likely caused by a problem other than heart disease (e.g., submersion, injury, or drug overdose). If the patient is a child or an infant, activate EMS after 2 minutes of resuscitation unless you have reason to think the patient's condition is caused by heart disease. Determining Breathlessness 8. The American Heart Association no longer recommends a separate step of "look, listen, and feel" for breathing. This takes time that delays compressions. Make a quick scan of the patient for signs of life or breathing (e.g., purposeful moving, chest wall movement). At the same time, check the pulse. You will still be able to look for signs of breathing while you are checking the pulse. The patient who is breathing adequately does not require resuscitation. Gasps are not effective breaths. If the patient is not breathing but definitely has a pulse, provide two ventilations (as explained later). Determining Pulselessness 9. At the same time that you evaluate breathing, determine Pulselessness by feeling for the carotid artery in an adult or a child or the brachial artery in an infant. The adult patient who has a pulse does not require chest compressions. If an infant or child has a pulse slower than 60 beats per minute, begin CPR (ventilations and chest compressions). 10. If the patient has a pulse but is not breathing, provide rescue breathing (artificial ventilations). Even experienced providers sometimes have difficulty evaluating the presence of a pulse, so unless you definitely feel a pulse in the adult patient, begin chest compressions. Assessing in A-B-C or C-A-B Sequence 11. Assessments of the ABCs are included in the steps just described. Keep the ABCs in mind throughout every patient encounter, whether or not resuscitation is under way. If the answer to any of the ABC questions that follow is no, take the appropriate steps to correct the situation: (a) Is the patient's airway open? (b) Is the patient breathing? (c) Does the patient have circulation of blood (a pulse)? 7 RESTRICTED RESTRICTED 8 RESTRICTED  RESTRICTED ASSESSMENT SPECIAL CONSIDERATIONS  As you approach the patient,  If the patient has signs of life, observe for signs of life: rise and fallproceed in A-B-C sequence Open the of the chest, moaning, wheezing, Airway With the head tilt, chin-lift coughing, or other sounds or method, then evaluate Breathing and movements. Circulation Consider whether the patient may have  When you reach the patient, a spine Injury and require the jaw-thrust assess for unresponsiveness by method. tapping the patient on the shoulder and shouting.  In an infant, check the brachial pulse.  Palpate the carotid pulse at the same time that you put your head close to the patient's mouth to observe more closely for chest movement and listen for sounds of breathing. MANAGEMENT SPECIAL CONSIDERATIONS  For adults, if there are no signs  Tailor your actions to the cause of of life and no pulse (or questionable the patient's condition and the resources pulse), activate the emergency available. If there is reason to believe the response system if not already done patient arrested because of a respiratory and, if there is no AED available, problem (e.g, drowning or overdose), proceed in C-A-B sequence. make ventilations a higher priority. Administer 30 Chest compressions.  If more than one rescuer is available, work in a coordinated fashion  Open the Airway with the to perform actions simultaneously or as head-tilt, chin-lift method, and restore efficiently as possible. Breathing by giving two ventilations.  Children and infants usually arrest because of respiratory, not cardiac,  If a child or infant has a pulse problems. but it is less than 60, begin  If the patient may have a spine ventilations and compressions. injury, use the jaw-thrust method.  If a pulse is present but breathing  Repeat the cycle of 30:2 is absent or abnormal, ventilate the compressions to ventilations. patient at the rate appropriate for the patient's age. 9 RESTRICTED  RESTRICTED 12. Keep in mind that the proper treatment will not necessarily occur in A-B-C order. If the patient appears lifeless and has no pulse, the above steps should be performed in C-A-B order with chest compressions performed before rescue ventilations. Positioning the Patient 13. When you have determined that the patient is unresponsive and has activated EMS, then do what you can to position the patient in a supine position (on the back). This may require helping the patient onto the floor or stretcher or onto his or her back if the patient was found in another position. If you have reason to suspect that the patient was injured, you or a helper must support the neck and hold the patient's head still and in line with the spine while you are moving, assessing, and providing care for the patient. Opening the Airway 14. Most airway problems are caused by the tongue. As the head tips forward, the tongue may slide into the airway, especially when the patient is lying on his or her back. When the patient is unconscious, the risk of airway problems is worsened because unconsciousness causes the tongue to lose muscle tone and the muscles of the lower jaw (to which the tongue is attached) to relax. Two procedures can help to correct the position of the tongue and thus open the airway. These procedures are the head-tilt, chin-lift maneuver and the jaw-thrust maneuver. Head-Tilt, Chin-Lift Maneuver 15. The head-tilt, chin-lift maneuver (Figure A-1) provides for maximum opening of the airway. It is useful on all patients who need assistance in maintaining an airway or breathing. It is one of the best methods for correcting obstructions caused by the tongue. However, since it involves changing the position of the head, the head-tilt, chin-lift maneuver should only be used on a patient whom you can be quite sure has not suffered a spinal injury. Follow these steps to perform the head-tilt, chin-lift maneuver: (a) Once the patient is supine, place one hand, on the forehead and the fingertips of the other hand under the bony area at the center of the patient's lower jaw. (b) Tilt the head by applying gentle pressure to the patient's forehead. 10 RESTRICTED  RESTRICTED (c) Use your fingertips to lift the chin and support the lower jaw. Move the jaw forward to a point where the lower teeth are almost touching the upper teeth. Do not compress the soft tissues under the lower jaw, which can press and close off the airway. (d) Do not allow the patient's mouth to close. To provide an adequate opening at the mouth, you may need to use the thumb of the hand supporting the chin to pull back the patient's lower lip, For your own safety (to prevent being bitten), do not insert your thumb into the patient's mouth. The head-tilt, chin-lift maneuver, side view. Inset photo shows MEDICAL ASSISSTANT's fingertips under the bony area at the center of patient's lower jaw. Jaw-Thrust Maneuver 16. The jaw-thrust maneuver is most commonly used to open the airway of an unconscious patient or one with suspected head, neck, or spinal injuries. Follow these steps to perform the jaw-thrust maneuver: (a) Carefully keep the patient's head, neck, and spine aligned, moving the patient as a unit into the supine position. (b) Kneel at the top of the patient's head. For greater comfort, you might rest your elbows on the same surface the patient is lying on. (c) Reach forward and gently place one hand on each side of the patient's lower jaw, at the angles of the jaw below the ears. 11 RESTRICTED  RESTRICTED (d) You can help to stabilize the patient's head by using your wrists or forearms. (e) Place your thumb on each side of the patient’s cheek bone. (f) Using your index fingers, push the angles of the patient's lower jaw forward. (g) You may need to retract the patient's lower lip with your thumb to keep the mouth open. (h) Do not tilt or rotate the patient's head. Remember: The purpose of the jaw-thrust maneuver is to open the airway without moving the head or neck. NOTE: The jaw-thrust maneuver is the only widely recommended procedure for use on patients with possible head, neck, or spinal injuries. The jaw-thrust maneuver, side view, Inset photo shows MEDICAL ASSISSTANT's finger position at angle of jaw, just below the ears. Airway Adjuncts 17. If you determine that patient does not have a patent airway, you must take action to secure it. The airway must be maintained throughout all care procedures: 12 RESTRICTED  RESTRICTED Types of Airway Adjuncts: (a) Oropharyngeal Airway (OPA). (b) Nasopharyngeal Airway (NPA). (c) Supraglottic Airway: (i) Laryngeal Mask Airway. (ii) I-Gel Airway. Rules for using airway adjuncts 18. Some general rules apply to use of Oropharyngeal airway and nasopharyngeal airway: (a) Use an Oropharyngeal airway only on patients who do not exhibit a gag reflex. (b) Open the patient airway manually before using an adjunct device. (c) When inserting the airway, take care not to push the patient’s tongue into the pharynx. (d) If the patient regain consciousness or develop a gag reflex, remove the airway immediately. Oropharyngeal airway (OPA) 19. Once a patient’s airway is opened, an Oropharyngeal airway can be inserted to help keep it open. An Oropharyngeal airway is a curved device, usually made of plastic that can be inserted into the patient’s mouth. The Oropharyngeal has a flange that will rest against the patient’s lips. The rest of device moves the tongue forward as it curves back to the pharynx. 20. There are standard sizes of OPAs for infant to large adult sizes. The airway adjunct cannot be used effectively unless you select the correct airway size for the patient. To determine the appropriate size oral airway, measure the device from the corner of the patient’s mouth to the tip of the earlobe on the same side of the patient’s face. An alternative method is to measure from the center of the patient’s mouth to the angle of the lower jaw bone. Do not use an airway device unless you have measure it against the patient and verified it as being the proper size. Airway practical use to be done during course. 13 RESTRICTED  RESTRICTED Nasopharyngeal airway (NPA) 21. The nasopharyngeal airway is commonly used device because establishing it often does no stimulate the gag reflex. This allows the nasopharyngeal airway to be used in patients who have a reduced level of responsiveness but still have an intact gag reflex. Other benefits include the fact that can be used when the teeth are clenched and when there are oral injuries. 22. You should carefully consider the use of a nasopharyngeal airway in a patient with signs of a basilar skull fracture. Use the soft, flexible nasal airway and do not the rigid, clear plastic airway in the field. The typical sizes for adults are 34, 32, 30, and 28 French. Airway practical use to be done during course. To insert a nasopharyngeal airway, follow these steps: (a) Measure the nasopharyngeal airway from the patient’s nostril to the tip of the earlobe or to the angle of the jaw. (b) Lubricate the outside of the tube with a water based lubricant before insertion. (c) Gently push the tip of the nose upward and insert the airway. Keep the patient’s head in neutral position. The bevel (angled portion at the tip) of the airway should point toward the base of the nostril or toward the septum (wall that separates the nostrils). 14 RESTRICTED  RESTRICTED (d) Insert the airway into the nostril and gently advance the airway along the floor of the nasopharynx until the flange rests firmly against the patient’s nostril. Never force a nasopharyngeal airway. Supraglottic Airway 23. There are many types of Supraglottic airways. These devices generally do not enter the trachea but rather isolate the glottic opening by occupying space in the larynx and hypo pharynx. 15 RESTRICTED  RESTRICTED 24. In most cases, insertion is a simple procedure that can be performed with the patient’s head in a neutral position. There are some different Supraglottic airways available and before using one, you should be thoroughly trained to the manufacturer’s specific standards. Recognizing the need for an Advanced Airway 25. In general, supra glottic airways are indicated when other basic airways management measures have failed. If proper positioning, manual airway opening and adjuncts cannot keep an airway open, a supra glottic airway may be of benefit. Also Supraglottic devices can help when an airway must be maintained over a relatively longer period, or as a bridge between simple maneuvers and endotracheal tubing. Supra glottic airways cannot be used if the patient has gag reflex. Airway practical use to be done during course. Examples of Supra Glottic Airways are: Laryngeal mask Airway and I-Gel Airway. Initial Ventilations and Pulse Check 26. The reason most apneic (non breathing) adults are not breathing is that the heart stopped. You will see very few adults with a pulse but with no breathing. Oxygen is often still in the patient's blood stream. Since this is common, you should start CPR with chest compressions, not ventilations, under ordinary circumstances. When the cause of the cardiac arrest is respiratory in nature, It may be reasonable to take a different approach and start with ventilations. In this case, deliver 2 breaths, each delivered over 1 second and of sufficient volume to make the chest rise. If the first breath is unsuccessful, reposition the patient’s head before attempting the second breath. If the second ventilation is unsuccessful, assume that there is a foreign body airway obstruction and perform airway clearance techniques (as described later). 16 RESTRICTED  RESTRICTED Rescue Breathing ADULT CHILD INFANT Age Puberty and older 1 yr-puberty Birth- 1 yr Ventilation duration 1 sec 1 sec 1 sec Ventilation rate 10-12 breaths/min 12-20 breaths/min 12-20 breaths/min 27. If initial ventilations are successful, you have confirmed an open airway. If the patient has no pulse, begin chest compressions with ventilations (as described later under "CPR"). If the patient has a pulse but breathing is absent or inadequate, perform rescue breathing. Rescue Breathing (Mouth-to-Mask Ventilation) 28. Mouth-to-mask ventilation is performed using a pocket face mask with a one-way valve. The pocket face mask is made of soft, collapsible material and can be carried in your pocket, jacket, or purse. The steps of mouth-to-mask ventilation are illustrated in table below. Gastric Distention 29. Rescue breathing can force some air into the patient's stomach, causing the stomach to become distended. This may indicate that the airway is blocked, that there is improper head position, or that the ventilations being provided are too large or too quick to be accommodated by the lungs or the trachea. This problem is seen more frequently in infants and children but can occur with any patient. 30. A slight bulge is of little worry, but major distention can cause two serious problems. First, the air-filled stomach reduces lung volume by forcing the diaphragm upward, second, regurgitation (the passive expulsion of fluids and partially digested foods from the stomach into the throat) or vomiting (the forceful expulsion of the stomach's contents) is a strong possibility. This could lead to additional airway obstruction or aspiration of Vomitus into the patient's lungs, When this happens, lung damage can occur and a lethal form of pneumonia may develop. 31. The best way to avoid gastric distention, or to avoid making it worse once it develops, is to position the patient's head properly, to avoid ventilation that are too force full and too quickly delivered, and to limit the volume of ventilations delivered, The volume delivered should be limited to the size breath that causes the chest to rise. This is 17 RESTRICTED  RESTRICTED why it is so important to watch the patient's chest rise as each ventilation is delivered and to feel for resistance to your breaths. Table; Position the patient and prepare to place and seat the mask firmly on the patient’s face Table: Open the patient's airway, and watch the chest rise as you ventilate through the one-way valve 32. When gastric distention is present, be prepared for vomiting. If the patient does vomit, roll the entire patient onto one side, (Turning just the head may allow for aspiration of vomitus as well as aggravation of any possible neck injury.) Manually stabilize the head and neck as you roll the patient. Be prepared to clear the patient's mouth and throat of vomitus with gauze and gloved fingers. Apply suction if you are trained and equipped to do so. 18 RESTRICTED  RESTRICTED Recovery Position 33. Patients who resume adequate breathing and pulse after rescue breathing or CPR and who do not require immobilization for possible spinal injury are placed in the recovery position. The recovery position allows for drainage from the mouth and prevents the tongue from falling backward and causing an airway obstruction. 34. The patient should be rolled onto one side. This should be done moving the patient as a unit, not twisting the head, shoulders, or torso. The patient may be rolled onto either side; however, it is preferable to have the patient facing you so monitoring and suctioning may be more easily performed. If the patient does not have sufficient respirations to support life, the recovery position must not be used. Place the patient supine and assist ventilations. FIGURE: for infants; determine circulation by feeling for a brachial pulse. NOTE: Do not initiate CPR on any adult who has a pulse. Providing Chest Compressions (Adult CPR) 35. After you have placed the patient supine on a hard surface and your hands are properly positioned on the CPR compression site: (a) Place the heel of your hand on the sternum between the nipples. Put your other hand on top of the first with your fingers interlaced. Straighten your arms and lock your elbows. You must not bend the elbows when delivering or releasing compressions. (b) Make certain that your shoulders are directly over your hands (directly over the patient's sternum). This will allow you to deliver compressions straight down onto the Site. Keep both of your knees on the ground or floor. 19 RESTRICTED  RESTRICTED (c) Deliver compressions STRAIGHT DOWN With enough force to depress the sternum of a typical adult 2 to 2.4 inches (5-6 cm). (d) Fully release pressure on the patient's sternum, but do not bend your elbows and do not lift your hands from the sternum, which can cause you to lose correct positioning of your hands. Your movement should be from your hips. Compressions should be delivered in a rhythmic, not a "jabbing," fashion. The amount of time you spend compressing should be the same as the time for the release. This is known as the 50:50 rule: 50 percent compression, 50 percent release. Providing Ventilations 36. Ventilations are given between sets of compressions. The mouth to-mask techniques described earlier for rescue breathing are used. One-Rescuer and Two-Rescuer CPR 37. Table on page 21 shows the techniques of one-rescuer CPR and two rescuers CPR for the adult patient and describes compression rates and ratios for CPR on adults, children, and infants. The AHA recommends using an AMBU bag for two- rescuer BLS. CPR Techniques for Children and Infants 38. The techniques of CPR for children and Infants are essentially the same as those used for adults. However, some procedures and rates differ when the patient is a child or an infant. (If younger than 1 year of age, the patient is considered an infant. Between 1 year and puberty, the patient is considered a child. Past the age of puberty, adult procedures apply to the patient. Keep in mind that the Size of the patient can also be an important factor. A very small 10-year-old who has reached puberty may have to be treated as a child.) 20 RESTRICTED RESTRICTED 21 RESTRICTED  RESTRICTED ONE RESCUER FUNCTIONS TWO RESCUERS Establish unresponsiveness Position patient If there's no response, call 1122 Call for an AED Check carotid pulse and breathing. (5—10 seconds) If no pulse Begin chest compressions DELIVER COMPRESSIONS 2—2.4 inches (5—6 cm) 100—120/min DELIVER VENTILATIONS Compression ventilation ratio 30:2 Continue Switch compressions every 5 and ventilations cycles to Limit pulse prevent checks fatigue CONTINUE PERIODIC ASSESSMENT 22 RESTRICTED  RESTRICTED NOTE: Wear gloves and use either a pocket mask with one-way valve or AMBU bag 39. For a child, CPR is conducted as for an adult, the chief difference in procedure being the hand position—using the heel of one or two hands—for chest compressions. To compare adult, child, and infant CPR, see Table above on page 22. 40. When CPR must be performed, adults, children, and infants are placed on their backs on a hard surface. For an infant, the hard surface can be the rescuer's hand or forearm. For an infant or a child, use the head-tilt, chin-lift or the jaw-thrust maneuver, but apply only a slight tilt for an infant. Too great a tilt may close off the infant's airway; however, make certain that the opening is adequate. (note chest rise during ventilation.) Always be sure to support an infant's head. Take these steps to establish a pulse in an infant or a child: (a) For an infant, you should use the brachial pulse. (b) For a child, determine circulation in the same manner as for an adult. Special Considerations in CPR (How to Know if CPR Is Effective) 41. To determine if CPR is effective, if possible have someone else feel for a carotid pulse during compressions and watch to see the patient's chest rise during ventilations. Listen for exhalation of air, either naturally or during compressions, as additional verification that air has entered the lungs. In addition, any of the following indications of effective CPR may be noticed: (a) Pupils constrict. (b) Skin color improves. (c) Heartbeat returns spontaneously. (d) Spontaneous, gasping respirations are made. (e) Arms and legs move. (f) Swallowing is attempted. (g) Consciousness returns. Infant CPR 42. As follows (a) For very small infant, encircle chest with fingers and overlap thumbs on the sternum just below an imaginary line connecting the nipples. 23 RESTRICTED  RESTRICTED (b) For an average-size infant, encircle chest with fingers and place thumbs side by side on the sternum just below an imaginary line connecting the nipples. (c) For an infant who is older or too large for you to be able to encircle the chest, place middle and ring fingers on sternum one finger-width below imaginary line connecting nipples. Measure distance by first placing, then raising, index finger. (d) Position fingers for chest compressions according to the age and size of the infant. The two-thumbs-encircling-hands method is preferred when two rescuers are present. 24 RESTRICTED RESTRICTED 25 RESTRICTED  RESTRICTED Performing chest compressions on a child. SPECIAL CONSIDERATION 43. Gestational age is an important consideration when determining the approach to a pregnant patient in cardiac arrest. (a) If the fundus is below the umbilicus or gestational age is known to be < 20 weeks, follow the adult CPR procedure. (b) If the fundus is at, or above the umbilicus or gestational age known to be > 20 weeks, follow the basic life support of pregnant patient. Additionally, there is unique consideration for CPR of pregnant patient in cardiac arrest with a fundus at or above umbilicus or fetal age known to be > 20 weeks. (c) In a pregnant patient with out of hospital cardiac arrest, prioritize transport over care at the scene. Following your local protocol for destination decision. (d) For a pregnant patient in cardiac arrest, at least three (and preferably four) team members are needed to perform high quality CPR. One to provide compression, one to provide continuous left uterine displacement and one (preferably two) to manage airway and breathing. (e) Left Uterine displacement: When the fundus is at or above the level of umbilicus or gestational age is known to be 20 weeks or later, left uterine displacement (LUD) must be provided continuously throughout the resuscitation effort and until the infant is delivered, even if return of spontaneous circulation (ROSC) is achieved. LUD relieves pressure placed on the inferior vena cava by the graved uterus, increasing venous return to the heart to maximize cardiac output. (f) To provide LUD: Position yourself on the patient’s left side. Reach across the patient, place both hands on the right side of the uterus, and pull 26 RESTRICTED  RESTRICTED the uterus to the left and up. Alternatively, position yourself on the patient’s right side. Place two hands on the right side of the uterus and push the uterus to the left and up. In most cases one will need two hands to sufficiently displace the uterus. Interrupting CPR 44. Once you begin CPR. You may interrupt the process for no more than 10 seconds to check for pulse and breathing or to reposition yourself and the patient. 45. In addition to these built-in interruptions, you may interrupt CPR to: (a) Move a patient onto a stretcher. (b) Move a patient down a flight of stairs or through a narrow doorway or halfway. (c) Move a patient into or out of the ambulance. (d) Suction to clear vomitus or airway obstructions (e) Allow for defibrillation or advanced cardiac life support measures to be initiated. (f) Assess the patient for signs of life when taking over CPR from someone else. (g) Switch positions to minimize fatigue. (When practical, no one on the team should compress the chest for more than 2 minutes at a time. Compressing the chest is very tiring, and rescuers are poor judges of when their compressions are no longer deep enough or fast enough.) 46. Whenever you must interrupt compressions, it is very important that you do it quickly to minimize the amount of time during which the patient is not circulating blood. When CPR is resumed, begin with chest compressions rather than with ventilations. 27 RESTRICTED  RESTRICTED ADULT CHILD INFANT Age Puberty and older 1 yr puberty Birth- 1 yr Compression At least 2 inches At least 1/3 AP At least 1 /3 AP depth diameter of chest diameter of chest (approximately 2 (approximately 1 ½ Inches) inches) Compression 100-120/min 100-120/min 100-120/min (new rate born 120/min) Each 1 sec 1 sec 1 sec ventilation Pulse check Carotid artery Carotid artery Brachial artery (upper location (throat) (throat) arm) One-rescuer 30:2 30:2 30:2 (alone) 15:2 (2 CPR 15:2 (2 rescuers) rescuers) compressions- 3:1 (new born) to- ventilations ratio When working After establishing After establishing After establishing alone: Call unresponsiveness— unresponsiveness unresponsiveness 1122 or before beginning and 2 minutes of and 2 minutes of emergency resuscitation unless resuscitation resuscitation unless dispatcher submersion, injury, unless heart heart disease present or overdose disease present When Not to Begin or to Terminate CPR 47. As discussed earlier, CPR should not be initiated when you find that the patient—even though unresponsive and perhaps not breathing—does have a pulse. Usually, of course, you will perform CPR when the patient has no pulse. However, there are special circumstances in which CPR should not be initiated even though the patient has no pulse: (a) Obvious mortal wounds. These include decapitation, incineration, a severed body, and injuries that are so extensive that CPR cannot be effectively performed (e.g., severe crush injuries to the head, neck, and chest). (b) Rigor mortis. This is the stiffening of the body and its limbs that occurs after death, usually within 4-10 hours. (c) Obvious decomposition. (d) A line of lividity. Lividity is a red or purple skin discoloration that occurs when gravity causes the blood to sink to the lowest parts of the body and collect there. Lividity usually indicates that the patient has been dead for 28 RESTRICTED  RESTRICTED more than 15 minutes unless the patient has been exposed to cold temperatures. Using lividity as a sign requires special training. (e) Stillbirth. CPR should not be initiated for a stillborn infant who has died hours prior to birth. This infant may be recognized by blisters on the skin, a very soft head, and a strong disagreeable odor. (f) Valid advance directive or Do Not Resuscitate (DNR) order. In all cases, if you are in doubt, seek a physician's advice. Once you have started CPR, you must continue to provide CPR until: (i) Spontaneous circulation occurs. (Then provide rescue breathing as needed.) (ii) Spontaneous circulation and breathing occur. (iii) Another trained rescuer can take over for you. (iv) You turn care of the patient over to a person with a higher level of training. (v) You receive a "no CPR" order from a physician or other authority per local protocols. (vi) There are three criteria that have been extremely accurate in determining when it is reasonable to stop CPR without missing anyone who has a chance of survival: (A) The arrest was not witnessed by EMS personnel or first responders. (B) There has been no return of spontaneous circulation (patient regains a pulse) after three rounds of CPR and rhythm checks with an automated external defibrillator (AED). (C) The AED did not detect a shock able rhythm and did not deliver any shocks. (D) If you turn the patient over to another rescuer, this person must be trained in basic cardiac life support. The Trained Health Care Provider versus the Lay Provider 48. As a MEDICAL ASSISSTANT, you will be regarded as a "trained health care provider" with regard to CPR. The training you receive is more in-depth than a lay rescuer or bystander might receive. The course for people who wish to learn CPR and have no medical background differs from the training a MEDICAL ASSISSTANT receives in the following ways: (a) Lay rescuers are not trained to check for a pulse before beginning compressions in CPR. If the patient is not breathing and does not otherwise 29 RESTRICTED  RESTRICTED respond (breathing, cough, or movement), the lay rescuer is supposed to begin compressions. (b) As a MEDICAL ASSISSTANT, you will be taught additional techniques that are not taught to lay rescuers, such as the two-thumbs-encircling hands technique for two- rescuer compression in infants. (c) Lay rescuers may be reluctant to do rescue breathing, especially on a stranger. Also, coordinating and timing both compressions and respirations is likely to be beyond the abilities of a lay provider. For these reasons, the current American Heart Association Guidelines recommend that the lay rescuer perform compressions without respirations. 49. It is possible for you to come upon a bystander performing CPR and see some of these differences in practice. If you ask the bystander, "Does the patient have a pulse?" the bystander might not have checked (and in fact was not required to do so). Remember that performing CPR is quite stressful for the layperson or bystander. In many cases CPR will be performed by a member of the patient's family. It is important to be supportive and use a nonjudgmental tone about the efforts undertaken by the layperson or bystander. Check the ECG monitor/defibrillator Automated External Defibrillators (AED) 50. An automated external defibrillator (AED) is a portable electronic device that automatically analyzes the patient’s heart rhythm and provides defibrillation, an electrical shock that may help the heart re-establish a perfusing rhythm. AEDs deliver defibrillation(s) to patients with two specific arrhythmias: ventricular fibrillation (VF) and Ventricular tachycardia (VT). When a patient experiences cardiac arrest, an AED should be applied as soon as it is readily available. Early use of an AED greatly increases the patient’s chance of survival. 30 RESTRICTED  RESTRICTED NOTE. For every 1-minute delay in CPR and defibrillation, a patient’s chance of survival is reduced by 7% to 10%. Using an AED 51. AED models function differently. Always follow the manufacturer’s instructions for the AED use in your facility. If CPR is in progress, continue CPR until the AED is turned on, the AED pads are applied and the AED is ready to analyze the heart rhythm. If you are alone and an AED is available, you should use it once you have determined the patient is in cardiac arrest. 52. To use an AED: (a) Turn the AED on and follow the prompts. Some AEDs turn on as soon as you open the case or lid. For others, you have to press a power button or pull a handle. (b) Remove or cut away clothing and undergarments to expose the patient’s chest. If the patient’s chest is wet, dry it using a towel or gauze pad. Do not uses an alcohol wipe to dry the skin because alcohol is flammable. (c) Apply pads appropriately sized for the patient’s age in the proper location on the bare chest. 31 RESTRICTED  RESTRICTED ADULT MALE ADULT FEMALE CHILD