Emergency Care Textbook Professional Responders-part-7.pdf

7 Circulatory Emergencies Key Content Cardiovascular Disease........... Angina..................................... Myocardial Infarction (MI)...... Congestive Heart Failure........ Cardiac Arrest.......................... Cardiopulmonary Resuscitation........................ Compressions..............

7 Circulatory Emergencies Key Content Cardiovascular Disease........... Angina..................................... Myocardial Infarction (MI)...... Congestive Heart Failure........ Cardiac Arrest.......................... Cardiopulmonary Resuscitation........................ Compressions....................... Team Approach.................... Using a Defibrillator............ Special Resuscitation Situations.......................... Post-Cardiac Arrest Care...... Cerebrovascular Accident (Stroke)................................. Transient Ischemic Attack (TIA).................................. CVA Assessment Scales........ 142 142 143 146 147 149 149 152 154 156 157 157 157 157 Introduction CIRCULATORY EMERGENCIES Circulatory emergencies are those that affect the heart or vascular system. While a circulatory emergency can often appear as a sudden, dramatic emergency, the underlying cause may be a condition that has been developing over a period of years or even decades. Because circulatory emergencies can deprive vital organs of oxygen, they are often immediately life-threatening. 141 CARDIOVASCULAR DISEASE Cardiovascular disease (CVD) is a term used to refer to a broad range of abnormal conditions affecting the heart and blood vessels. Many specific diseases and conditions are grouped under this umbrella term, including diseases of the heart itself (such as congenital heart disease) and of the vascular system (such as peripheral arterial disease). CVD is one of the leading causes of death both in Canada and worldwide. Examples of cardiovascular diseases include: Coronary heart disease (CHD) (also called coronary artery disease, a disease of the blood vessels supplying the heart muscle itself). Cerebrovascular disease (disease of the blood vessels supplying the brain). Congenital heart disease (genetic defects in the heart that are present at birth). Deep vein thrombosis and pulmonary embolism (blood clots in the legs, which can move to the heart and lungs). Peripheral arterial disease (disease of blood vessels that reduces circulation to extremities, especially the legs). CHAPTER 5 CIRCULATORY EMERGENCIES CVD also significantly increases the risk of acute circulatory emergencies such as cerebrovascular accident (CVA), also referred to as stroke, and myocardial infarction (MI), also referred to as heart attack. Both of these emergencies are immediately life-threatening. 142 Arteriosclerosis (also called atherosclerosis) occurs when arteries become hardened, narrowed, and less elastic. This occurs gradually, as cholesterol and plaque (fatty deposits) build up on the interior walls of the arteries (Figure 7–1, a). As plaque accumulates, the arteries become narrower, reducing the volume of blood that can flow through them and thereby reducing the supply of oxygen to the affected tissues. When arteriosclerosis occurs in the coronary arteries (supplying blood to the heart), this results in coronary heart disease (CHD). When coronary heart disease (or another condition) significantly reduces blood flow to the myocardium (heart muscle), this is referred Coronary arteries a b Unblocked Partially blocked Completely blocked Figure 7–1, a-b: a, Buildup of material on the inner walls of coronary arteries reduces blood flow to the heart muscle and may cause a myocardial infarction; b, the coronary arteries supply the heart muscle with blood. to as acute myocardial ischemia. This may result in angina pectoris (chest pain) or myocardial infarction (heart attack). Because arteriosclerosis develops gradually, it can go undetected for many years. Even with significantly reduced blood flow to the myocardium, there may be no signs and symptoms. Most people with arteriosclerosis are unaware of it. Some may suffer a myocardial infarction or even cardiac arrest without any previous warning. ANGINA Some patients with coronary heart disease may experience intermittent chest pain or pressure that is exacerbated by exertion and stress and reduced when these factors are removed. This type of pain is called angina pectoris, commonly referred to as angina. It occurs when the oxygen demands of the heart exceed the available supply of oxygen-rich blood, such as during periods of physical activity or emotional stress. This lack of oxygen can cause a constricting chest pain that may spread to the neck, jaw, and arms. Pain associated with angina usually lasts less than 10 minutes. A patient who is diagnosed with Stable angina usually occurs while a patient is exercising or under emotional stress and follows a predictable pattern. Usually, the pain can be relieved with a combination of rest and medication: A patient experiencing stable angina should cease any physical activity that could increase the body’s oxygen demands and rest in a position of comfort. Recognizing the difference between stable angina (which is usually not lifethreatening) and the symptoms of a myocardial infarction (MI) is crucial. The patient should track how long his or her angina typically lasts and which factors are effective in reducing it so that this baseline can be used to evaluate any future cases. Unstable angina is angina that is not typical for the patient. It may occur when the patient is at rest, last longer than 10 minutes, or not respond to medication. Unstable angina may also be more painful or last longer each time it occurs, or may happen with increasing frequency. Unstable angina occurs when the myocardium (heart muscle) is receiving insufficient oxygenated blood. It is similar to an MI, except that the effects are usually temporary and do not result in permanent damage. Unstable angina is a warning sign that an MI may be imminent. Because the signs and symptoms of unstable angina and of an MI are difficult to distinguish in the field, you should provide essentially the same care for the two conditions. MYOCARDIAL INFARCTION (MI) The coronary arteries supply the myocardium with oxygen-rich blood (Figure 7–1, b). If one or more of these arteries is blocked by arteriosclerosis or a blood clot, the oxygen supply to the myocardium will be interrupted and the heart muscle will become hypoxic. When the hypoxic myocardium cells begin to die (myocardial necrosis), this is called a myocardial infarction (MI) or heart attack. An MI may interrupt the heart’s electrical system, resulting in arrhythmias that can prevent blood from circulating effectively. An MI can also lead to cardiac arrest if the heart is so damaged that it cannot continue to beat. Signs and Symptoms of a Myocardial Infarction The most prominent symptom of a myocardial infarction is persistent chest pain or discomfort (Figure 7–2). However, it may not always be easy to distinguish between the pain of an MI and chest pain caused by indigestion, muscle spasms, or other conditions. Brief, stabbing chest pain or pain that feels more intense when the patient bends or breathes deeply is usually not caused by an MI. If you are unsure whether the patient is experiencing angina or an MI, treat the patient for an MI. Figure 7–2: The most prominent symptom of a myocardial infarction is persistent chest pain. CIRCULATORY EMERGENCIES angina will often have a prescribed medication (typically sublingual nitroglycerin in a spray or pill form). Nitroglycerin is a vasodilator, which means that it causes blood vessels to dilate (expand). This allows blood to pass more easily through narrowed vessels, increasing the flow of oxygenated blood to the myocardium and reducing the workload of the heart. 143 As a blockage or reduction of blood flow to the heart progresses, some patients experience symptoms such as chest pain, pressure, or discomfort, which are early warning signs that the heart is not receiving enough oxygen-rich blood. Others may suffer heart attacks or even cardiac arrest without any warning signs or symptoms. If a blockage in an artery of the heart is not treated quickly, the affected heart muscle tissue will die. The pain of a myocardial infarction can range from mild discomfort to an unbearable crushing sensation in the chest. The patient may describe it as pressure, squeezing, tightness, aching, or a heavy sensation in the chest. Often the patient feels pain in the centre of the chest behind the sternum. It may spread to the shoulder, arm, neck, or jaw (Figure 7–3). The pain is constant and usually not relieved by resting, changing position, or taking medication. When assessing a patient who complains of chest pain or pressure, ask the OPQRST questions (see page 92) to determine whether the qualities of the pain suggest an MI. Tiredness General malaise Moist or sweaty skin Pale or bluish skin Pale or bluish skin Change in pulse Pain radiating to arm, shoulders, neck, or jaw Persistent chest pain Mild, unfocused chest discomfort Although the signs and symptoms of a myocardial infarction are often obvious, someone experiencing an MI can also have relatively mild symptoms. The patient may feel little or no chest pain, and may have other signs and symptoms such as fatigue, nausea, and vomiting. Other signs include a mild, unfocused chest discomfort that gets continually stronger, gets better with rest, and gets worse with activity. These soft signs are more common among women, older adults, and patients with diabetes. Another sign of an MI is dyspnea. The patient may be experiencing tachypnea because the body is trying to get more oxygen to the heart. Depending on the patient’s general condition, his or her pulse may be faster or slower than normal, or its rhythm may be irregular. The patient’s skin may be pale or bluish, particularly around the face. Some patients will sweat profusely during a myocardial infarction. These signs and symptoms result from the stress that the body experiences when the heart is not working effectively. Since any myocardial infarction may lead to cardiac arrest without immediate interventions, it is important to recognize and act on these signs and symptoms. Most patients die within one to two hours after the first appearance of MI signs and symptoms. Many patients who have MIs delay seeking care: Denial is a common reaction. Nearly half of patients wait two or more hours before going to the hospital. They may dismiss the symptoms as indigestion or muscle soreness. CIRCULATORY EMERGENCIES While not every MI is accompanied by chest pain, the presence of severe chest pain or discomfort that lasts longer than 10 minutes is a key indicator that should not be ignored. 144 Any patient experiencing severe chest pain, chest pain that lasts longer than 10 minutes, or chest pain that is accompanied by other myocardial infarction signs and symptoms should be treated for MI. Gastric discomfort or indigestion Flu-like symptoms Breathing difficulty Figure 7–3: Signs and symptoms of a myocardial infarction may be different for each individual. A silent MI occurs when a myocardial infarction is not recognized and, therefore, advanced medical care is not obtained. This can happen to anyone but occurs most often in those who experience soft signs—typically women, patients with diabetes, and older adults. Care for Myocardial Infarctions The most important step in providing care for an MI is the early recognition of the signs and symptoms. During your assessment, it’s important to remember that all MI signs and symptoms may not be present: Your care will be based on an overall picture of the patient. Don’t withhold care because some signs and symptoms are absent. Keep the patient in a comfortable position throughout assessment and care (Figure 7–4). Acetaminophen (e.g., Tylenol®) and ibuprofen (e.g., Advil®) do not have the same effect as ASA in reducing damage due to myocardial infarctions. Do not substitute. ASA is contraindicated for patients with asthma or for patients with bleeding conditions (e.g., ulcers). Nitroglycerin is a vasodilator medication often prescribed for angina. It may come in the form of a pill or a sublingual spray (Figure 7–6). The patient should be resting in a comfortable position, or in the position found, when taking nitroglycerin. Once absorbed into the body, nitroglycerin enlarges the blood vessels to improve the flow of blood to the myocardium. This increases the quantity of oxygen reaching the heart, which can help to reduce the patient’s chest pain. If necessary, you may assist the patient in taking prescribed nitroglycerin after checking the Six Rights of Medication. If your scope of practice includes the administration of nitroglycerin, you may provide it to the patient (with appropriate medical oversight). For further information about assisting with medication, refer to Chapter 22. Figure 7–5: Low-dose ASA. CIRCULATORY EMERGENCIES Because most MIs result from blood clots in the coronary arteries, reducing clot formation can reduce damage to the heart during an MI. Any patient experiencing chest pain should chew 160 to 325 mg of acetylsalicylic acid (ASA), depending on what is available (Figure 7–5). Do not repeat the dosage. ASA, commonly sold under the brand name Aspirin®, thins the blood and reduces the formation of clots, possibly minimizing the damage to the heart muscle. Figure 7–4: When assessing and caring for a patient suffering an MI, ensure you keep them in a position of comfort. Patients may find it easier to breathe when they are seated upright (High Fowler’s position) or semi-seated (Fowler’s position). 145 A patient will often know when to take his or her prescribed nitroglycerin. Ask the patient, “Would you normally take your medication at this time?” If the patient answers “yes” (taking into consideration the signs and symptoms), this is a good indication that the circumstance warrants the use of nitroglycerin. Nitroglycerin reduces blood pressure, so low blood pressure is a contraindication. It is important to check the patient’s blood pressure before and after the patient takes nitroglycerin. Specific BP values will vary based on local protocols, etc., but in general, systolic pressure lower than 90 mmHg is a contraindication for nitroglycerin. Before suggesting that the patient take nitroglycerin, ask if he or she has recently taken erectile dysfunction medication for any reason. If the patient has taken sildenafil (e.g., Viagra®) or vardenafil (e.g., Levitra®) in the previous 24 hours, or tadalafil (e.g., Cialis®) in the previous 48 hours, advise him or her not to take the nitroglycerin because the combination can cause a fatal lowering of blood pressure. Other contraindications include an allergy or known hypersensitivity to nitroglycerin or other nitrates, uncorrected hypovolemia, and severe anemia. The nitroglycerin dose may be repeated every 3 to 5 minutes until the pain is relieved or until 3 doses have been administered. Blood pressure must be reassessed prior to each dose. CIRCULATORY EMERGENCIES Be calm and reassuring when caring for someone experiencing a myocardial infarction. Comforting the patient helps reduce anxiety and eases some of the discomfort. 146 Observe any changes in appearance or behaviour. Since a myocardial infarction may lead to cardiac arrest, be prepared to perform CPR. Any patient you suspect of having an MI should be placed in the rapid transport category, though typically the first dose of indicated medications will be taken at the scene. Figure 7–6: Nitroglycerin spray is one of the common forms that this medication comes in. CONGESTIVE HEART FAILURE Congestive heart failure (CHF) is an abnormal condition in which the heart’s pumping ability is diminished. This may be the result of an MI, valvular disease, ischemic heart disease, or any other disease that affects the myocardium. The result is that fluids and blood back up into the lungs or body tissues. CHF may affect the left side of the heart, the right side of the heart, or both sides. The left side of the heart receives blood from the lungs, so left-sided heart failure causes blood to back up into the alveoli. The right side of the heart receives blood from the body’s veins, so right-sided heart failure causes blood to back up and collect in the body’s tissues, especially in the extremities. Left-Sided Heart Failure In an MI, it is often the left ventricle that is damaged. Also, in chronic hypertension, the left ventricle suffers the long-term effects of having to pump against restricted arteries in the extremities (peripheral arteries). Whatever the cause, the left ventricle can lose the ability to effectively pump blood through the body. Blood coming into the left ventricle from the lungs backs up, causing fluid to leak into the lungs (pulmonary edema). Signs and symptoms of left-sided heart failure may include: Shortness of breath. Increased respiratory rate. Right-Sided Heart Failure Right-sided heart failure usually occurs due to left-sided heart failure. When the left ventricle fails, increased fluid pressure is transferred back through the lungs. Eventually, the right side is unable to keep up with the increased workload, damage occurs, and heart failure results. Right-sided heart failure may also occur as a result of a pulmonary embolism, long-standing COPD, or an MI. When the right side loses its pumping power, blood backs up in the body’s veins. This usually causes pooling of fluid in the tissues, resulting in swelling of the extremities (peripheral edema). This will be most noticeable in the feet and lower legs. Bedridden patients may also experience swelling of the lower back. Signs and symptoms of right-sided heart failure may include: Shortness of breath. Swelling of the lower extremities and/or lower back. Urinating more frequently at night. Jugular venous distension (JVD). Tachycardia or cardiac arrhythmia. Weakness and fatigue. Fainting. Right-sided heart failure by itself is seldom a lifethreatening emergency. A change in lifestyle and possibly medications are the definitive treatments for this condition. Jugular Venous Distention (JVD) Jugular venous distension (JVD) refers to a visible swelling of the jugular vein in the neck. It is an indication of increased blood volume in the patient’s circulatory system, or anything that interferes with the flow of blood into the right atrium or the right ventricle. Essentially, JVD increases whenever the venous return of blood to the heart overwhelms the heart’s ability to pump it back out to the body. It is primarily seen in patients with right-sided heart failure. JVD is most easily assessed when a patient is in the Semi-Fowler’s position (inclined 30 to 45 degrees). It should be visible in a supine patient as well. CARDIAC ARREST Cardiac arrest occurs when the heart stops circulating blood: A patient who goes into cardiac arrest will not have a pulse, and respiration will soon cease (if it has not already). The cessation of both circulation and respiration is referred to as clinical death. Clinical death may be reversible through immediate interventions. Cardiac arrest is a life-threatening emergency because the body’s vital organs, including the brain, stop receiving oxygen-rich blood, causing their cells to begin dying in a matter of minutes. The irreversible damage caused by the death of brain cells is known as biological death, which is irreversible. Any patient in cardiac arrest requires immediate interventions in the form of CPR, defibrillation, and advanced cardiac life support (ACLS). Common Causes of Cardiac Arrest Cardiovascular disease is the most common cause of cardiac arrest in adults: Many cardiac arrests are the result of damage caused by MIs. Other causes include asphyxiation, exposure to certain drugs, severe chest trauma, severe blood loss, and electrocution. Strokes and other injuries to the brain can also cause the heart to stop. A child or infant’s heart is usually healthy, unless it has a genetic abnormality. In children and infants, cardiac emergencies usually result from CIRCULATORY EMERGENCIES History of severe shortness of breath when the patient is lying down, which gets better when standing. Cyanosis. Coughing up foamy sputum (sometimes bloodtinged). Increased heart rate. Wheezing. Pale, cool, clammy skin. Panic, restlessness, agitation. Normal to high blood pressure. Confusion and disorientation. 147 non-cardiac causes, typically respiratory arrest. Common causes of cardiac emergencies in infants and children include drowning, smoke inhalation, burns, poisoning, airway obstructions, and traumatic injuries. Signs of Cardiac Arrest Someone in cardiac arrest will be unresponsive, have no palpable pulse, and not be breathing effectively (though agonal respirations may be present). The patient’s heart has either stopped beating or is beating so weakly or irregularly that it does not produce a pulse. Cardiac arrest can happen suddenly, without prior indication. This is referred to as sudden cardiac arrest (SCA). A patient who appears to be unresponsive and breathing may in fact be in cardiac arrest. Ensure that you assess the patient’s respiration thoroughly and confirm whether the carotid pulse is present (or the brachial pulse, in the case of infants). The surest sign of cardiac arrest is the absence of a pulse. Cardiac Arrhythmias and Defibrillation CIRCULATORY EMERGENCIES When a patient is in cardiac arrest, his or her heart will either be stopped completely or have an arrhythmia that essentially prevents it from circulating blood. An extreme arrhythmia in which the heart is simply quivering (rather than truly contracting) is referred to as fibrillation. In some cases, stopping the fibrillating heart momentarily can allow it to spontaneously resume an effective rhythm. 148 A defibrillator is a device used to analyze the heart’s rhythm and deliver an electric shock, causing the myocardium to contract forcefully. It consists of a defibrillator unit connected to two electrodes contained in adhesive pads. When the pads are placed on a patient and the shock button is pressed, a powerful electrical current travels between the pads, through the patient’s heart, delivering a shock. Defibrillators are only effective for patients with certain heart rhythms, often referred to as shockable rhythms: Defibrillators can analyze the patient’s heart rhythm to determine whether a shock is advised. The most commonly encountered defibrillator is the automated external defibrillator (AED). The healthy adult heart usually displays sinus rhythm (SR), the normal conduction of electrical impulses without any disturbances. Disturbances or variations in the conduction of electrical impulses within the heart are called arrhythmias (used interchangeably with dysrhythmias). Arrhythmias range from benign to life-threatening. There are four major arrhythmias that are immediately lifethreatening: asystole, pulseless electrical activity (PEA), ventricular tachycardia (VT), and ventricular fibrillation (VF). ASYSTOLE Asystole is the total absence of electrical activity in the heart: The heart is not pumping and the patient has no pulse. Defibrillation will not be effective for this rhythm (Figure 7–7). PULSELESS ELECTRICAL ACTIVITY (PEA) Pulseless electrical activity occurs when there is electric activity in the heart, but it is insufficient to produce a pulse. The heart may either contract ineffectively or not contract at all. Defibrillation will not be effective for this rhythm (Figure 7–8). VENTRICULAR TACHYCARDIA Ventricular tachycardia (VT) occurs when the heart’s ventricles are contracting too rapidly to fill with blood between contractions. In some cases, a patient with a VT rhythm will have a rapid, ineffective pulse. In others, the heart will be beating so rapidly and ineffectively that there will be no palpable pulse (pulseless VT). Defibrillation is indicated for pulseless VT (Figure 7–9). VENTRICULAR FIBRILLATION Ventricular fibrillation (VF) is a chaotic discharge of electrical activity that causes the heart muscle to quiver. Patients with this arrhythmia have no pulse. VF is a life-threatening condition that will quickly deteriorate to asystole within a few minutes. Defibrillation can be effective for this rhythm (Figure 7–10). Because not all rhythms are shockable, defibrillators are able to analyze a patient’s heart rhythm and indicate whether a shock is advised. Figure 7–7: Asystole (non-shockable rhythm). Figure 7–9: Pulseless VT (shockable rhythm). Figure 7–8: Pulseless electrical activity (non-shockable rhythm). Figure 7–10: VF (shockable rhythm). Some devices begin to analyze automatically when the defibrillator’s pads are applied, and others have an analyze button that must be manually activated by the operator (usually referred to as semi-automated defibrillators). Advanced cardiac life support personnel use defibrillators that can be toggled between automatic, semi-automatic, and fully manual operation. Once started, CPR should be interrupted only to perform critical interventions (such as clearing the airway) or when there are obvious changes in the patient’s condition (such as a return of spontaneous circulation, or ROSC). CARDIOPULMONARY RESUSCITATION A patient in cardiac arrest needs cardiopulmonary resuscitation (CPR). CPR consists of a combination of assisted ventilations and chest compressions, which artificially replicate the functions of the lungs and heart. For a patient in cardiac arrest, CPR increases the chance of survival by keeping the brain supplied with oxygen until the patient can receive advanced medical care. CPR consists of cycles, which are sets of compressions and ventilations given in a fixed ratio. These can be performed by one responder alternating between compressions and ventilations, but a team approach is both easier and more strongly associated with positive patient outcomes. The basic ratio for adults is 30 compressions for every 2 ventilations, but this ratio can vary based on the age of the patient and whether CPR is being performed alone or with another responder (see Table 7–1 on page 152). Chest compressions move blood through the circulatory system by creating pressure within the chest cavity (intrathoracic pressure) and by directly compressing the heart. For compressions to be most effective, the patient should be flat on his or her back on a firm surface. Give compressions smoothly, and maintain a steady rhythm. Compressions should be given at a rate of approximately 100 to 120 per minute: This works out to 30 compressions in the space of 15 to 18 seconds. COMPRESSION FRACTION/OFF-CHEST TIME When compressions are interrupted, the pressure in the circulatory system begins to drop almost immediately. When you resume compressions after a break of even a few seconds, the first compressions you perform will be rebuilding the patient’s blood pressure, not circulating blood effectively. For this reason, it is crucial that interruptions to compressions be kept to a minimum. This is another reason why tworesponder CPR is recommended whenever possible: Because one responder is maintaining the airway and keeping the ventilation device in the correct position, there is no need to readjust these when switching between compressions and ventilations, saving crucial seconds. CIRCULATORY EMERGENCIES Early defibrillation increases the chance of surviving cardiac arrest for patients with shockable rhythms. Compressions 149 The percentage of total CPR time in which the patient is receiving compressions is referred to as the compression fraction, and the remaining time (spent applying defibrillator pads, checking vitals, etc.) is referred to as off-chest time. By minimizing interruptions to compressions, you can maximize the compression fraction and perform the most effective CPR. HAND POSITION Pressing on the centre of the chest (on the lower half of the sternum) allows you to give the most effective compressions, regardless of the patient’s age. For an adult or child, place the heel of one hand over the patient’s sternum, then place your other hand on top and grip the lower hand with your fingers. This standard hand position must be modified for the smaller bodies of infants. There are two appropriate compression methods for infants: Using two fingers, and encircling the infant’s torso with your hands to give compressions with your thumbs. The technique you select depends on the infant’s size and whether you are alone (Figure 7–11). You must use the two-finger method if the infant’s torso is too large to encircle. If you cannot make a complete ring around the infant’s chest with your thumb and fingers, use the two-finger method. The two-finger method is also recommended if you are performing CPR alone: It is very difficult to maintain an open airway and give ventilations effectively while encircling the infant’s chest with your hands. The two-finger method is similar to the method used for adults and children, but compressions are given with the tips of your index and middle fingers rather than the entire hands. Place your fingers in the centre of the sternum, just below the nipple line, and give compressions with the pads of your fingers (Figure 7–12). Keep your fingers at a right angle to the chest so that your compressions press directly downwards. If you are performing two-responder CPR and the infant’s torso is small enough to encircle with your hands, the encircling method is the recommended approach. One responder holds the infant’s chest with his or her hands, spreading the fingers around the infant’s back and placing both thumbs on the lower half of the infant’s sternum (Figure 7–13). The first responder gives compressions by pressing on the sternum with his or her thumbs, and the second responder monitors the infant’s pulse, manages the airway, and gives ventilations. RESPONDER POSITION Correct body position makes CPR more effective and also reduces responder fatigue. Body position is mainly relevant for adults and children: Infants are small enough that CPR can be performed in any comfortable and effective position. Kneel beside the patient (or stand beside a patient who is on a multi-level stretcher), facing the chest. You should be close enough that your arms form a right angle to the chest when you begin compressions. Lean forward and straighten your arms so that your shoulders are directly above your hands (Figure 7–14). Lock your elbows and press straight down onto the patient’s sternum. CIRCULATORY EMERGENCIES Infant requires CPR 150 Hands can encircle chest Performing CPR with partner Performing CPR alone Hands cannot encircle chest Two-finger compression method Encircling chest method Figure 7–11: Decision tree for two-finger compressions versus encircling method for infant CPR. Figure 7–12: The two-finger compressions method for infant CPR. Figure 7–13: The encircling method for infant CPR. Compressing the chest requires less effort in this position. If you are on your knees, avoid resting on your legs: The weight of your upper body creates the force needed to compress the chest. Push with the weight of your upper body, not with the muscles of your arms. Push straight down and avoid rocking back and forth, as rocking results in less effective compressions and uses unnecessary energy. If you find that you are pushing too deeply, consider performing compressions with one hand only. This is especially useful for smaller patients. If you are alone, you can use your free hand to help keep the patient’s airway open. CHEST RECOIL Performing high-quality CPR has the following key components: Ensuring an appropriate rate of chest compressions Ensuring an appropriate depth of chest compressions When you complete each compression, allow the chest to recoil completely. Do not rest or lean on the patient’s chest between compressions. When the chest recoils completely, it allows the heart to expand and fill with blood, which is then forced into the circulatory system with the next compression. This is also when the heart’s own tissues receive oxygen. CPR ventilations may be given with resuscitation mask or a BVM using the techniques described in Chapter 6. The recommended depth for chest compressions varies based on the age of the patient. For adults, the chest should be compressed at least 5 cm (about 2 in.). Avoid pressing to a depth greater than 6 cm (2.4 in.). In children and infants, the compression depth is more usefully represented as a fraction of the chest’s total depth. When performing compressions on a child, infant, or neonate, compress to a depth of at least one-third of the anteroposterior (frontto-back) diameter of the chest. Figure 7–14: Kneel next to the patient so that your arms form a right angle to the chest. Lean forward, straighten your arms, and press straight down onto the patient’s sternum. CIRCULATORY EMERGENCIES CHEST COMPRESSION DEPTH 151 Allowing full chest recoil between compressions Maximizing compression fraction (minimizing off-chest time) Avoiding excessive ventilation should begin CPR while the second (Responder B) deploys the defibrillator and requests any additional resources that may be required. When Responder B is available, he or she moves to the patient’s head to maintain an open airway and hold the BVM in place (Figure 7–15). Responder A continues to give chest compressions and squeezes the BVM to provide ventilations. These components combine to create the most effective CPR possible, increasing the chance of a positive patient outcome. Using a choreographed team approach to CPR can help ensure that these key components are present, so it is preferable whenever possible. The ratio of compressions to ventilations can be different when you are working as a team (see Table 7–1 below). Team Approach When a patient is in cardiac arrest, time is a crucial factor. Interventions must be performed immediately, and unnecessary delays can reduce the patient’s chance of survival. For this reason, effective co-operation and communication between responders is crucial to patient outcomes. When a patient is in cardiac arrest and two responders are present, the first (Responder A) ADULT Responder B checks the effectiveness of the compressions by feeling for the carotid pulse (or the brachial pulse in infants) while Responder A is giving compressions. Responder B should provide feedback to Responder A about the effectiveness of the compressions, as determined by the strength of the pulse they produce. Note that a CHILD INFANT TABLE 7–1: CPR SUMMARY CIRCULATORY EMERGENCIES ADULT 152 CHILD INFANT NEONATE Hand Position: Two hands on sternum One or two hands on sternum Two fingers on sternum (just below nipple line) OR Encircling method Two fingers on sternum (just below nipple line) OR Encircling method Compression Depth: 5 cm (about 2 in.) 1/3 of the chest depth 1/3 of the chest depth 1/3 of the chest depth One-Responder Cycle: 30 compressions 2 ventilations 30 compressions 2 ventilations 30 compressions 2 ventilations 3 compressions 1 ventilation Two-Responder Cycle: 30 compressions 2 ventilations 15 compressions 2 ventilations 15 compressions 2 ventilations 3 compressions 1 ventilation Compresion Rate: 100–120 per minute (30 compressions in 15–18 seconds) 100–120 per minute (30 compressions in 15–18 seconds) 100–120 per minute (30 compressions in 15–18 seconds) 100–120 per minute (30 compressions in 15–18 seconds) patient who has lost a significant amount of blood may not have a strong pulse even if compressions are effective. To avoid fatigue and maintain a high quality of compressions, the two responders should switch roles after approximately 2 minutes (5 cycles for most patients) of continuous CPR. When Responder A completes the last ventilation, Responder B moves immediately into position beside the patient’s chest while Responder A moves to the head. There is no need to move to the other side of the patient. Responder B begins compressions immediately to reduce off-chest time. If more than two responders are available, one responder should assume the role of team leader. In some situations, this role will be clear: In a fire department, for example, the officer will usually be the team leader. The team leader’s role is to coordinate the actions of the other responders, record patient information, and communicate with other incoming personnel. If more advanced personnel arrive on the scene, such as an advanced life support team or code team (in a hospital setting), it is the team leader who communicates with the advanced personnel, providing them with a report of the situation and the patient’s status. When transferring care of a patient in cardiac arrest, try to minimize offchest time. The goal is to achieve a near-seamless continuation of CPR. Figure 7–15: When responders are working as a team, one responder maintains the airway and holds the BVM. available if possible. Whenever CPR is interrupted to move or reposition a patient, the patient should be quickly reassessed. The patient and equipment must be firmly secured before moving. It is often best to leave the stretcher partially elevated, midway between the lowest and highest position. This lets the responder walk in a slightly bent position, allowing for more Dynamic CPR is performed while a patient is being moved (Figure 7–16). The keys to making it work are planning and adaptability. The responder’s goal is to maintain the highest-quality CPR, with the fewest interruptions possible, while quickly and efficiently moving with the patient. The exit route should be planned while you are entering the scene: This should become a habit whenever you arrive at a scene. Moves can be communicated ahead of time with clear, concise commands to other responders involved. Lifting and turning can cause a patient to vomit, so it is important to have suction and extra airways Figure 7–16: Dynamic CPR. CIRCULATORY EMERGENCIES Dynamic CPR 153 effective compressions. If the stretcher is too low or too high relative to the responder, compressions will be less effective and more tiring. A resuscitation mask can be used to give ventilations during dynamic CPR. After being secured to the patient’s head with a strap, this allows the option of performing mouth-to-mask ventilations or using a BVM. When the mask is secured over the patient’s mouth, the airway should be monitored closely: If the patient vomits, it may be concealed by the mask. For an infant, you may be able to perform dynamic CPR while carrying the patient. Using a Defibrillator The large majority of sudden cardiac arrests involve a shockable heart rhythm (VT or VF), so a defibrillator should always be used when a patient is in cardiac arrest. As soon as you determine that the patient is in cardiac arrest, deploy the defibrillator: If two responders are present, one responder should begin CPR while the second prepares the defibrillator and applies the pads to the patient. The unit will need to be activated, and the pads may need to be connected to the unit with electrical leads (if they are not preconnected). CIRCULATORY EMERGENCIES If available, select the most suitable pads for the patient (e.g., pediatric pads for a child). Pediatric pads are typically smaller (to accommodate the smaller chest size) and deliver a lower-intensity shock. If age-appropriate pads are not available, adult pads are acceptable. Defibrillation is not indicated for neonates (0 to 28 days old). Some defibrillators will detect the size of the patient and adjust the shock level automatically: Ensure that you are familiar with all the details of how your defibrillator works. 154 First, expose and prepare the patient’s chest. If it is wet, dry it quickly. If the patient has a large quantity of chest hair (enough that it interferes with the adhesion of the pads), quickly shave the areas where the pads will be affixed. Attach the pads to the patient’s chest as directed by the defibrillator’s manufacturer. Most pads have illustrations showing the correct placement. Typically, one pad is placed on the upper-right side of the chest and the other on the lower-left side (Figure 7–17). If the patient’s chest is too small to allow at least 2.5 cm (1 in.) of space between the pads, place one pad on the front of the patient’s chest (anterior) and one on the back (posterior). The defibrillator may be used with standard defibrillation pads only on adults and children who are 8 years old or more or who weigh more than 25 kg (55 lb.). For children who are less than 8 years old or weigh less than 25 kg (55 lb.), use infant/ child reduced-energy defibrillation electrodes. Pause CPR to allow the defibrillator to analyze the patient’s heart rhythm. Some devices do this automatically, and some (semi-automated defibrillators) require you to press an analyze button. To avoid interfering with the analysis, do not touch the patient or the defibrillator while this analysis is performed (Figure 7–18). The defibrillator will notify you when the analysis is complete. Activating the defibrillator as soon as cardiac arrest is confirmed allows the defibrillator to begin analyzing the patient immediately, and most defibrillators will also record the actions taken by responders and the times that they occur, creating a record of the treatment provided. Figure 7–17: Typical defibrillator pad placement. If the defibrillator detects a rhythm that indicates the need for a shock, ensure that no one is touching the patient and press the shock button. Compressions should be continued while the AED charges. The necessary interruption of CPR for the administration of a shock is referred to as the perishock pause. While it is crucial that no one touch the patient while the shock is administered, CPR compressions should be resumed immediately after the shock is complete. Continue CPR, listening for the defibrillator’s prompts. Defibrillator Care and Maintenance You must ensure that your defibrillator is ready for use at all times. To arrive at the scene of a cardiac arrest with a defibrillator that is not functioning properly could result in the death of the patient. At the beginning of each shift: Ensure that the battery is fully charged. If possible, have a backup battery with you. Ensure that all necessary components are with the unit. Ensure that you have several sets of pads with you, including pediatric and infant pads (if available), and that they are within their expiration date. Modern defibrillators require minimal maintenance and include various self-diagnostic features. You should familiarize yourself with the visual and/or audio warnings that indicate a low battery or a malfunction. Read the manufacturer’s documentation thoroughly, and contact the manufacturer for more information if necessary. The manufacturer’s documentation will indicate how to maintain and care for the particular defibrillator you are using. It should be disinfected after each use. Always handle the defibrillator carefully: Avoid jostling or dropping it. Figure 7–18: Ensure that no one touches the patient or the defibrillator while the defibrillator analyzes the patient’s heart rhythm. Defibrillation Precautions The following precautions must be taken when using a defibrillator: DO NOT USE A DEFIBRILLATOR IN A MOVING VEHICLE The motion of the vehicle can interfere with the defibrillator’s analysis of the patient’s heart rate, resulting in a shock being advised when it is not needed (or vice versa). Some modern defibrillators are able to filter out external movement: Consult the manufacturer’s guidelines. In most cases, it is advisable to pull over and stop the vehicle while the defibrillator analyzes the patient’s rhythm. DO NOT DEFIBRILLATE A PATIENT IN THE PRESENCE OF FLAMMABLE MATERIALS Do not use a defibrillator if materials such as gasoline are present. A defibrillator may produce a spark when the shock is delivered, which could ignite flammable materials. For the same reason, avoid using alcohol to clean the patient’s chest before applying the pads. You should also keep free-flowing oxygen away from the patient during defibrillation. Remove any oxygen-delivery devices while the shock is delivered, and use caution around oxygen in general. CIRCULATORY EMERGENCIES If the defibrillator determines that no shock is advised, resume CPR and follow the defibrillator’s prompts, reanalyzing after 5 CPR cycles. If the defibrillator advises a shock and then later advises against a shock, this indicates that the patient’s condition has changed: Quickly reassess the patient before proceeding. 155 DO NOT TOUCH A PATIENT WHILE THE SHOCK IS DELIVERED A defibrillator necessarily delivers a shock powerful enough to stop the human heart, so ensure that the electrical current travels through the patient only. Make sure that no one is touching the patient when a shock is delivered, and if the patient is touching a conductive surface (e.g., the metal frame of a stretcher), ensure that no one is touching that surface, either. Special Resuscitation Situations PREGNANT WOMEN When performing CPR on a visibly pregnant woman, putting a blanket or cushion under her right hip will help blood return to the heart. However, do not interrupt CPR to find an object. It is safe to use a defibrillator normally on a pregnant woman. TRANSDERMAL MEDICATION PATCHES A defibrillator pad should not be placed over a transdermal medication patch (e.g., nitroglycerin or nicotine), as the patch may block the transfer of the energy to the heart and may cause small burns on the skin. Remove any patches from the chest and wipe the area clean before attaching the electrode pads. Ensure that you are wearing gloves, as the medication in these patches is designed to be absorbed through the skin. CIRCULATORY EMERGENCIES IMPLANTED PACEMAKERS AND IMPLANTED CARDIOVERTERDEFIBRILLATORS 156 A patient may have a pacemaker or cardioverterdefibrillator (ICD) implanted in his or her chest. If you see a small scar and a matchbox-sized lump on the chest, ensure that the electrodes are positioned at least 2.5 cm (1 in.) away. If an ICD is already in shock sequence (e.g., the patient’s muscles contract in a manner similar to that observed during external defibrillation), allow 30 to 60 seconds for the ICD to complete the treatment cycle before delivering a shock from the external defibrillator. In most situations, a patient is considered a child if he or she is over the age of 1 year but has not reached the onset of puberty. For the purposes of using a defibrillator, however, a patient is considered a child if he or she is between the ages of 1 and 8 years. Both infants and children can be defibrillated, but neonates cannot. BODY JEWELLERY If a piece of jewellery (e.g., a necklace or body piercing) is within 2.5 cm (1 in.) of the defibrillator pad placement, remove the jewellery before applying the pad. TRAUMA TO THE TORSO It is safe to perform CPR and place defibrillator pads on the chest as usual if the trauma does not interfere with their placement. PATIENTS IN WATER If the patient is in the water, remove the patient before defibrillation. A shock delivered in water could be conducted to responders or bystanders. Quickly wipe the patient’s chest dry and attach the defibrillator pads normally. RAIN OR SNOW If it is raining or snowing, ensure that the patient is as dry as possible and sheltered from the weather. This should be done as quickly as possible: Throwing a tarp (or other improvised cover) over yourself and the patient can provide the necessary shelter. If there is a safe, dry area in very close proximity, consider moving the patient (so long as this causes only a minimal delay). Wipe the patient’s chest dry. As always, follow all of the manufacturer’s precautions and operating instructions. NEONATAL RESUSCITATION Rescucitation is indicated for any neonate with a heart rate less than 60 bpm. Resuscitation methods must be adjusted when the patient is a neonate (from birth to 28 days old). Because the cause of cardiac arrest in neonates is almost always respiratory in origin (not cardiac), there is more of a focus on ventilations: The ratio of compressions to ventilations is 3:1. Defibrillation is not indicated for neonatal patients. patients may experience permanent deficits if tissue damage occurs. Post-Cardiac Arrest Care Transient Ischemic Attack (TIA) In some cases, a patient receiving CPR will regain a pulse, especially when a defibrillator is incorporated. This is called return of spontaneous circulation (ROSC). Such a patient must be monitored very closely. Check the pulse regularly, and be prepared to resume CPR if the heart stops again. Keep the defibrillator pads attached to the patient’s chest. TIAs are sometimes called mini-strokes. Like a stroke, a TIA is caused by reduced blood flow to part of the brain, most commonly as a result of a blood clot. Unlike a stroke, the signs and symptoms of a TIA disappear within a few minutes or hours as the patient’s body clears the blockage and blood flow returns to normal. CEREBROVASCULAR ACCIDENT (STROKE) A cerebrovascular accident (CVA), also called a stroke, is a disruption of blood flow to a part of the brain. The affected brain tissue quickly becomes hypoxic and suffers damage. The effects of a stroke vary based on which part of the brain is affected: The patient will experience deficits in the areas that are controlled by the damaged tissue (speech, motor skills, memory, etc.). Effects can range from minor to catastrophic, depending on the location and extent of the damage. A transient ischemic attack (TIA) is similar to a stroke in its signs and symptoms, but usually resolves quickly without permanent tissue damage. It is caused by a temporary restriction in blood flow to part of the brain and resolves when the blockage clears. A patient will usually survive a TIA without any lasting effects, though some Even if stroke signs and symptoms disappear, the patient is not out of danger. A TIA is sometimes referred to as a warning stroke, as someone who has experienced a TIA is at a significantly increased risk of having a CVA. Aside from the duration of signs and symptoms, a TIA is essentially identical to a CVA. TIA patients require immediate medical care as well: Don’t delay transport to see whether a patient’s condition changes. Recognizing a TIA and getting prompt medical treatment can help to identify why the TIA occurred and allow the patient to receive appropriate treatment (medication or surgery). Ultimately, this may prevent a stroke from occurring in the future. Causes of Cerebrovascular Accidents (CVA) There are two main causes of CVAs: Either an artery in the brain is blocked (ischemic stroke), or an artery in the brain ruptures (hemorrhagic stroke), spilling blood into the surrounding tissues (Figure 7–19). ISCHEMIC STROKES Ischemic strokes occur when a cerebral artery becomes blocked or narrowed, resulting in severely restricted blood flow (ischemia) to brain tissues. The blockage may develop in a cerebral artery over time (thrombotic stroke) or may be caused by a piece of material that is carried to the brain from elsewhere in the body (embolic stroke). More than 4 out of 5 CVAs are ischemic strokes. CIRCULATORY EMERGENCIES The return of the patient’s pulse may or may not be accompanied by the resumption of respiration. Either ventilate the patient or provide assisted ventilations as necessary. A patient who has experienced cardiac arrest is likely to be at least moderately hypoxic, so high-flow supplemental oxygen is indicated. Monitor the patient’s airway and be prepared to provide suction or other interventions if necessary. Any patient who has experienced cardiac arrest must receive advanced medical care as soon as possible, even if normal circulation and respiration have resumed. 157 Clot the tissues that are normally supplied by the ruptured artery may also become hypoxic and suffer damage as a result of the reduced blood flow. Subarachnoid hemorrhage occurs when an artery on the surface of the brain bursts, spilling blood into the subarachnoid space between the brain and the skull. This often manifests as a sudden and severe headache, reaching peak intensity within a few seconds. Rupture Figure 7–19: A CVA can be caused by a clot or rupture. Thrombotic strokes occur when a blood clot (thrombus) develops in a cerebral artery. They are often caused by the build-up of plaque associated with cardiovascular disease. Embolic strokes occur when a piece of material (embolus) forms outside of the brain and is carried to the cerebral arteries by the circulatory system. The embolus may be solid, liquid, or gas. The most common type of embolus is a clot that forms in diseased carotid blood vessels or from abnormally contracting chambers in the heart and then becomes detached and carried to the brain. Signs and Symptoms of CVA and TIA The signs and symptoms of a CVA or TIA vary based on which brain tissues are affected: The person will have deficits in the areas controlled by that tissue. If the language centre is affected, for example, the person may have difficulty communicating. A person may experience weakness (hemiparesis) or paralysis (hemiplegia) on one side of the body (Figure 7–20). More than one area of the brain can be affected. A person experiencing a CVA or TIA may experience any of the following signs and symptoms: Sudden weakness and/or numbness of the face, arm, or leg, usually only on one side of the body Difficulty speaking or understanding speech Blurred or dimmed vision CIRCULATORY EMERGENCIES HEMORRHAGIC STROKES 158 Hemorrhagic strokes occur when there is a break in one of the brain’s blood vessels. This causes blood to spill (hemorrhage) into either the brain’s tissue (intracerebral hemorrhage) or the space between the brain and the skull (subarachnoid hemorrhage). Hemorrhagic strokes can result from head injuries, hypertension, or a ruptured aneurysm (a weakened section of an artery wall). Intracerebral hemorrhage occurs when a blood vessel within the brain tissue bursts and spills blood into the surrounding tissues. In addition to damaging the brain cells at the site of the rupture, Figure 7–20: Weakness or numbness, often on one side of the face, is a sign of stroke. Pupils of unequal size Sudden, severe headache Dizziness Confusion Changes in mood Ringing in the ears Unresponsiveness or changes in responsiveness Loss of bowel or bladder control Care for CVA and TIA A patient experiencing a CVA or TIA is in a lifethreatening situation and requires advanced medical care immediately. Time is a crucial factor in the treatment of patients experiencing CVAs, so these patients are always in the rapid transport category. You should not delay transport unless it is absolutely necessary. Ideally, the patient will be transported to a stroke centre where thrombolytic therapy is available. When notifying the hospital of the patient’s condition, it is important to include the time of symptom onset so that treatment can be planned accordingly. A patient experiencing a CVA or TIA may have difficulty managing his or her airway. Do not give a patient with a suspected CVA anything to eat or drink (NPO, or no products orally). Position the patient so that you can either manually clear the airway (recovery position) or easily provide suction. If a patient must be rolled into the recovery position and is experiencing weakness or paralysis on one side, position the patient with the affected side of the body downwards. A stroke can make the patient fearful and anxious; therefore, it is important to comfort and reassure the patient. Often, the patient is confused and does not understand what has happened. CIRCULATORY EMERGENCIES 159 CVA Assessment Scales The following two scales are commonly used to assess a patient who has had a suspected CVA. FAST When assessing a patient with a suspected CVA, the acronym FAST will focus your questions on the most relevant areas: FACE—facial numbness and/or weakness, especially on one side A RM—arm numbness and/or weakness, especially on one side SPEECH—slurred speech or difficulty speaking or understanding TIME—when did signs and symptoms first appear (or when was the person last known to be well)? CIRCULATORY EMERGENCIES Time also refers to the urgency of care: A person with a suspected CVA must receive advanced medical care as soon as possible, as the thrombolytic drugs used to treat many CVAs are only effective in a short window of time following the onset of signs and symptoms. 160 CINCINNATI PRE-HOSPITAL STROKE SCALE (CPSS) The Cincinnati Pre-hospital Stroke Scale (CPSS) is a set of simple tests that can be used to assess facial droop, arm weakness, and speech abnormalities in a patient suspected of having a CVA. If the patient has abnormal results in any of these areas, you should suspect a CVA. Facial droop: Have the patient show his or her teeth or smile. Normal: Both sides of the face move equally. Abnormal: One side of the face does not move as well as the other side. Arm weakness: Have the patient close both eyes and hold his or her arms out straight for 10 seconds. Normal: Both arms move equally or neither arm moves at all. Abnormal: One arm does not move or arms drift unequally. Speech abnormalities: Have the patient repeat a well-known saying (e.g., “The early bird gets the worm.”) Normal: The patient uses the correct words and does not slur. Abnormal: The patient uses the incorrect words, slurs the words, or does not speak at all. SUMMARY Key Components of High-Quality CPR Ensuring an appropriate rate of chest compressions Ensuring an appropriate depth of chest compressions Allowing full chest recoil between compressions Maximizing compression fraction (minimizing off-chest time) Avoiding excessive ventilation LIFE-THREATENING ARRHYTHMIAS Defibrillation Indicated? Description Name Asystole Electrical activity is totally absent: no pulse. No Pulseless electrical activity (PEA) Electrical activity is present, but insufficient to produce a pulse. No Ventricular tachycardia (VT) Ventricles contract too rapidly for the heart to refill with blood between contractions. Pulse will be rapid and ineffective or undetectable entirely. Yes Ventricular fibrillation (VF) Chaotic discharge of electrical activity causes the heart muscle to quiver: no pulse. Yes ADULT CHILD INFANT NEONATE Hand Position Two hands on sternum One or two hands on sternum Two fingers on sternum (just below nipple line) OR Encircling method Two fingers on sternum (just below nipple line) OR Encircling method Compression Depth 5 cm (about 2 in.) 1/3 of the chest depth 1/3 of the chest depth 1/3 of the chest depth One-Responder Cycle 30 compressions 2 ventilations 30 compressions 2 ventilations 30 compressions 2 ventilations 3 compressions 1 ventilation Two-Responder Cycle 30 compressions 2 ventilations 15 compressions 2 ventilations 15 compressions 2 ventilations 3 compressions 1 ventilation Compression Rate 100–120 per minute 100–120 per minute 100–120 per minute 100–120 per minute (30 compressions in (30 compressions in (30 compressions in (30 compressions in 15–18 seconds) 15–18 seconds) 15–18 seconds) 15–18 seconds) Signs and Symptoms of Myocardial Infarction (MI) Tiredness General malaise Moist or sweaty skin Pale or bluish skin Change in pulse Flu-like symptoms Mild, unfocused chest discomfort Gastric discomfort or indigestion Breathing difficulty Persistent chest pain Pain radiating to arm, shoulders,  neck, or jaw CIRCULATORY EMERGENCIES CARDIOPULMONARY RESUSCITATION (CPR) SUMMARY 161 SUMMARY TEAM APPROACH TO CPR Responder B Responder A 1. Begin CPR. 1. Deploy defibrillator and request additional resources if necessary.  ove to patient’s head to maintain airway and hold BVM in 2. M position.  erform chest compressions and squeeze 3. Check effectiveness of compressions by feeling carotid pulse 2. P BVM to provide ventilations. (or brachial pulse in infants) and provide feedback.  fter 2 minutes (5 cycles for most 3. A 4. After 2 minutes (5 cycles for most patients), switch places with patients), switch places with Responder B. Responder A. 5. Continue CPR. 4. Continue CPR. USING A DEFIBRILLATOR FAST CVA (STROKE) ASSESSMENT MODEL 1. Select the most suitable pads for the patient. F Face—facial numbness and/or weakness, especially on one side A Arm—arm numbness and/or weakness, especially on one side S Speech—slurred speech or difficulty speaking or understanding T Time—when did signs and symptoms first appear (or when was the person last known to be well)? 2. Expose the patient’s chest and ensure it’s dry.  ttach the defibrillator pads; typically, in the 3. A upper-right- and lower-left side of the chest, at least 2.5 cm (1 in.) apart.  ause CPR to let defibrillator analyze patient’s 4. P heart rhythm. Shockable Rhythm 5. E  nsure no one is touching the patient and press the shock button. After the shock, resume compressions. Unshockable Rhythm 5. Resume CPR. 6. C  ontinue CPR and follow 6. Reanalyze after defibrillator’s prompts. 5 cycles. CINCINNATI PRE-HOSPITAL STROKE SCALE (CPSS) Factor CIRCULATORY EMERGENCIES Facial droop 162 Arm weakness Speech abnormalities Method Interpretation Have the patient show his or her teeth or smile. Normal: Both sides of the face move equally. Have the patient close both eyes and hold arms out straight for 10 seconds. Normal: Both arms move equally or neither arm moves at all. Have the patient repeat a wellknown saying (e.g., “The early bird gets the worm.”) Normal: The patient uses the correct words and does not slur. Abnormal: One side of the face shows impaired movement. Abnormal: One arm does not move or arms drift unequally. Abnormal: The patient uses the incorrect words, slurs the words, or does not speak at all.