BLS For Health Care Providers Course

BLS for Health Care Providers Course
By:
Dr. Nariman Singmamae
M.B.B.S (DMC), M.Em.Med (UKM)
Lecturer & Emergency Physician
UNIMAS/SGH
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1 Part 1
INTRODUCTION
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2
Introduction
Each year, approximately 1500 to 2000 Malaysians suffer a heart attack.
About 50% of them die outside the hospital without getting medical help.
When the heart stops, death is virtually certain if no resuscitation is given within
the first 10 minutes.
During this short period, the victims life hangs on the quick response of
bystanders.
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Introduction
If you are a bystander in this situation, would you know what to do to keep the
victim alive until expert help arrives?
By Performing CPR
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WhatWhyHow To Do CPR
Introduction
What is CPR?!
CPR is an emergency procedure for restoring the breathing and heartbeat of an
unconscious victim.
It is a combination of mouth-to-mouth breathing and chest compressions.
The primary objective is to deliver continuous flow of oxygen to the lungs and
brain.
CPR essentially buys time for the victim until AED and emergency care arrive.
Early CPR is the second critical link in the Chain of Survival.
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TIME IS MYOCARDIUM!!
Tiktoktiktok
TIME
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Introduction
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Probability of Survival Is Related to 2 Intervals:
(1) Collapse to Defibrillation and (2) Collapse to CPR
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Collapse to start of CPR: 1, 5, 10, 15 (min)
Probability of
survival to
hospital
discharge
Collapse to defibrillation interval (min)
Introduction
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What is the Chain of Survival?
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The Chain of Survival comprises 5 (five) vital links that can save a life in
cardiac emergencies:
1.Early recognition and access
2.Early CPR
3.early defibrillation
4.effective advance cardiac life support
5.integrated post cardiac care
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What is an AED?
An Automated External Defibrillator (AED) is:
A small portable electrical device that automatically analyses potentially
life threatening cardiac rhythms in a patient and treats it by
1.Defibrillation
2.Application of an electrical shock to allow the heart to re-establish
normal rhythms.
.It is designed to be used primarily by first responders in cardiac
emergencies who may not be fully trained in Advanced Cardiac Life
Support (ACLS).
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What is an AED?
Early defibrillation, the third critical link in the Chain of Survival, can
greatly improve survival rates for out-of-hospital cardiac arrests caused by
irregular heart rhythms (ventricular fibrillation).
Defibrillation works best in the first few minutes after the onset of cardiac
arrest. If it is initiated too late, the heart may not respond to the electric
therapy.
For every minute of delay in giving CPR and defibrillation following
collapse, the survival rate decreases by 7-10%.
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Objectives
1.To understand the importance of the Chain of Survival.
2.To understand the rescuers role and response to cardiac arrest victims.
3.To demonstrate knowledge and skills in CPR.
4.To demonstrate knowledge of using AED.
5.Focus on practical skills with intensive hands-on training during the
course.
6.Build confidence in performing quality CPR as participants.
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Part 2
AHA 2010
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Summary of Key Issues and Major Changes
LAY RESCUER ADULT CPR
1.The simplified universal adult BLS algorithm has been created (figure 2)
2.Refinements have been made to recommendations for immediate recognition and
activation of the
emergency response system based on signs of unresponsiveness, as well as
initiation of CPR if the
victim is unresponsive with no breathing or no normal breathing (i.e. victim is only
gasping).
3.Look, listen, and feel for breathing has been removed from the algorithm.
4.Continued emphasis has been placed on high-quality CPR (with chest
compressions of adequate rate
and depth, allowing complete chest recoil after each compression, minimizing
interruptions in
compressions, and avoiding excessive ventilation).
AHA 2010
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LAY RESCUER ADULT CPR
There has been a change in the recommended sequence for the lone rescuer to
initiate chest
compressions before giving rescue breaths (C-A-B rather than A-B-C). The lone
rescuer
should begin CPR with 30 compressions rather than 2 ventilations to reduce delay to
first
compression.
Compression rate should be at least 100/min (rather than "approximately
100/min).
Compression depth for adults has been changed from the range of 1 to 2 inches to
at least 2
inches (5 cm).
These changes are designed to simplify lay rescuer training
AHA 2010
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AHA 2005
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AHA 2010

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HEALTHCARE PROVIDER BLS
Because cardiac arrest victims may present with a short period of seizure-like
activity or agonal gasps that may confuse potential rescuers, dispatchers should be
specifically trained to identify these presentations of cardiac arrest to improve
cardiac arrest recognition.
Dispatchers should instruct untrained lay rescuers to provide Hands-Only CPR for
adults with sudden cardiac arrest.
Refinements have been made to recommendations for immediate recognition and
activation of the emergency response system once the healthcare provider
identifies the adult victim who is unresponsive with no breathing or no normal
breathing (i.e., only gasping).
AHA 2010
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The healthcare provider briefly checks for no breathing or no

normal breathing (i.e., no breathing or only gasping) when the
provider checks responsiveness.
The provider then activates the emergency response system and
retrieves the AED (or sends someone to do so).
AHA 2010

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The healthcare provider should not spend more than 10 seconds checking for a
pulse, and if a pulse is not definitely felt within 10 seconds, should begin CPR and
use the AED when available.
Look, listen, and feel for breathing has been removed from the algorithm.
Increased emphasis has been placed on high-quality CPR (compressions of
adequate rate and depth, allowing complete chest recoil between compressions,
minimizing interruptions in compressions, and avoiding excessive ventilation).
Use of cricoid pressure during ventilations is generally not recommended.
Compression rate is modified to at least 100/min from approximately 100/min.
AHA 2010

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Rescuers should initiate chest compressions before giving rescue breaths (C-A-B
rather than A-B-C). Beginning CPR with 30 compressions rather than 2
ventilations leads to a shorter delay to first compression.
Compression depth for adults has been slightly altered to at least 2 inches (about
5 cm) from the previous recommended range of about 1. to 2 inches (4 to 5 cm).
Continued emphasis has been placed on the need to reduce the time between the
last compression and shock delivery and the time between shock delivery and
resumption of compressions immediately after shock delivery.
There is an increased focus on using a team approach during CPR.
AHA 2010

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BLS healthcare provider algorithm 2010
AHA 2010
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AHA 2010
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Features
Adult
Children
Infants
Recognition
Unresponsive
No breathing, gasping, No
pulse check
Unresponsive
No breathing, gasping, No
pulse check
Unresponsive
No breathing, gasping,
No pulse check
CPR sequence:
C-A-B
C-A-B
C-A-B
Compression rate:
= 100/min
= 100/min
= 100/min
Compression depth:
= 2 inches
= . AP diameter
=. AP diameter
Airway
Head-tilt-chin lift
(trauma: jaw thrust)
Head-tilt-chin lift
Head-tilt-chin lift
Compression:
ventilation ratio
30:2
30:2 (single)
15:2 (2 rescuer)
30:2 (single)
15:2 (2 rescuer)
Defibrillation:
AED, minimize interruption
before & after shock
AED, minimize
interruption before &
after shock
AED, minimize
interruption before &
after shock
AHA 2010
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ELECTRICAL THERAPIES
AHA 2010
Integration of AEDs into the Chain of Survival system for public places.
Consideration of AED use in hospitals.
AEDs can now be used in infants if a manual defibrillator is not available.
Shock first versus CPR first in cardiac arrest.
1-shock protocol versus 3-shock sequence for VF.
Biphasic and monophasic waveforms.
Escalating versus fixed doses for second and subsequent shocks.
Electrode placement.
External defibrillation with implantable cardioverter-defibrillator.
Synchronized cardioversion
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AHA 2005
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AHA 2010

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PART 3
CPR (ADULT)
Step by Step Approach
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ADULT CPR
Remember DRS ABCD

1)Assess for Danger
2)Assess the Response
3)Shout/Call for Help
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ADULT CPR

4) Open the Airway Head Tilt Chin Lift
5) Assess for Breathing for (5 sec) breathing / abnormal breathing
(gasping for air)
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ADULT CPR
6) Pulse Check
maintain a head tilt with one hand with one hand on the victims forehead, locate
the trachea using 2 or 3 fingers of the other hand,
slide these 2 or 3 into the groove between the trachea and the muscles of the neck
where you can feel the carotid pulse
palpate the artery for at least 5 seconds and NO more than 10 seconds
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ADULT CPR
7) Cardiac compression
Adequate rate (30 compression in each cycle) = 100 beats/min
Adequate Depth (5cm) or (2 inches)
Allow complete chest recoil after each compression
Minimizing interruptions in compressions
Avoiding excessive ventilation
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ADULT CPR
8) Give (2) Breaths allow adequate chest rise
9) Repeat the cycle (30:2)* for 5 times in 2 minutes
10) Defibrillation (AED)
* One rescuer and two rescuer are the same
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Methods For Delivering Effective Breathing
Mouth-to-Mouth where the rescuer seals the victims mouth with their own
mouth, pinches the soft part of the nose closed (gently, but firmly), and then
blows air into the victims mouth.
Mouth-to-Nose is used when the victim has sustained facial injuries that prevent
using the mouth. The rescuer closes the victims mouth, covers the nose with
their mouth, breathes gently, then releases the victims jaw to allow exhalation.

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Methods For Delivering Effective Breathing
Mouth-to-Nose-&-Mouth is the preferred method when resuscitating a child, as
the rescuers mouth can cover and seal both the childs nose and mouth.
Mouth-to-Mask is safest method (especially if you do not know the victim or
their medical health) and also the most desirable for rescue breathing as it lessens
the risk of cross-infection.
(It works in similar fashion as mouth-to-mouth. Masks come in various forms but
they are all used
the same way. The mask is fitted firmly over the victims nose and mouth and the
rescuer delivers
air via the valve or tube thus avoiding direct contact with the victims mouth or
exhaled air)
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Mouth-to-Mask Technique
16669_02_0145PPB
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How To Administer An Effective Rescue Breathing?!
Mouth-to-Mouth
Tilt the victim's head back by placing one hand on his or her forehead and pushing
gently.
Pinch the nostrils shut with your thumb and finger and tilt the chin upward by
placing the
fingers of your other hand near the chin. This will ensure that the airway is open and
accessible.
Take a breath to fill your lungs with air and place your mouth over the adult
victim's mouth,
ensuring a tight seal.

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Blow into the victim's mouth and check to see if the chest rises. Maintain head
and chin tilt, take your mouth away and watch the chest fall. An effective breath
is one in which you see the chest rise and fall.
Try up to 5 attempts to give 2 effective rescue breaths to the unconscious victim.
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How To Administer An Effective Breathing?!
Remove your mouth and take a normal breath between rescue breath attempts.
If you are having difficulty giving an effective breath check the victims mouth
for an obstruction. If one is present remove it. Re-check to make sure the head is
tilted back and chin is tilted up. Also check circulation.
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How To Administer An Effective Breathing?!

Bag-Valve-Mask Components
BLS for Health Care Providers Course 16669_02_0146P
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The 'EC' Technique - utilizes to obtain a seal with the mask.
This position involves the thumb and index finger holding the
mask and the inferior and superior mask borders, respectively.
The other three fingers hold the mandible while performing the
jaw thrust.
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One-Person BVM Technique
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The two-provider technique, one person should hold the mask with
both hands, while the other provider bags the patient .
A common location of air leak is located around the nasal bridge,
which should be detected when attempting ventilation.
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Two-Person BVM Technique
16669_02_0147P
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PART 4
CPR ( Children)
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CPR for children
Children (1 year of age to puberty)
Remember DRS ABCD / DRS CABD
Step No.
Step Code
Action
Assess for Danger
Assess for Response
Shout for Help
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CPR for children
Step No.
Step Code
Action
Open the Victims Airway
Check Whether the victim is Breathing / not Breathing or

Gasping
Check for Pulse ( for 5 Sec not more than 10 sec )
if no pulse
Start Cardiac Compression 30:2 ( 1-Rescuer )
15:2 ( 2 Rescuer)
- The depth of Cardiac compression about 1/3 diameter

(5cm in children) & (4cm in infant)
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CPR for children
Step No.
Step Code
Action
Give (2) Breath about one second per breath &

allow Chest recoil
Repeat the cycle for 5 times in (2) minutes

9
Attach the victim to Defibrillator if available &

minimize interruption before and after shock
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PART 5
Relieving Choking in Adult & Children
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Choking in Adult & Children
*Early recognition of the airway obstruction is the key to successful

outcome.
* It is important to distinguish this Emergency from fainting, fainting, heart

attack , seizure , drug overdose or other condition that cause respiratory
failure but required different treatment.
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*Foreign body may cause either mild or severe airway obstruction
Mild Airway Obstruction Signs
Rescuer Action
Good air exchange
As long as good airway exchange continues

encourage the victim to continue
spontaneous coughing and breathing effort
Responsive and can cough forcefully
Do not interfere with the victim's own

attempt to expel the foreign body but stay
with victim and monitor the condition
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Rescuer Action
Responsive and can cough forcefully
If mild airway obstruction persists

activate the emergency response
system
May wheeze between coughs
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Severe Airway Obstruction Signs
Rescuer Action
Poor or no air exchange
Ask the victim if he or she is choking .
If the victim nods yes and can not talk,

severe airway obstruction is present and
must activate the emergency response
system
Weak, ineffective cough or no cough at all
High- pitched noise while inhaling or no

noise at all
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Severe Airway Obstruction Signs
Increase respiratory difficulty

Possible cyanosis
Unable to speak
Clutching the neck with the thumb

and fingers making the universal sign
Unable to move air
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Use Abdominal Thrust ( Heimlich Maneuver) to relive choking in adults &

children over 1 year .
Do Not use abdominal thrust in infant.
Use each individual thrust with the intent of relieving the obstruction.
It may be necessary to repeat the thrust several times to clear the airway.
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if the victim is pregnant or obese,

perform Chest Thrust instead of
Abdominal Thrust.
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Abdominal Thrust in a Responsive Standing Victim
(Adult & Children)
Step
Action
Stand or kneel behind the victim and wrap your arms around the victims
waist
Make a fist with one hand
Place the thumb side of your fist against the victims abdomen , in the
midline slightly above the navel &well below the breastbone
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Abdominal Thrust in a Responsive Standing Victim (Adult & Children)
Step
Action
Gasp your fist with your other hand and press your fist into the victim<s
abdomen with a quick upward thrust
Repeat thrusts until the object is expelled from the airway or the victim
become unresponsive
Give each new thrust with a separate distinct movement to relieve the
obstruction
If you find a Responsive Choking Victim lying down, perform abdominal thrust
with victim lying down
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*Abdominal Thrust in Unresponsive Victim (Adult & Children)
The cause of unresponsiveness is the airway obstruction
1)If in Adult, Activate EMS, Open the Airway. Remove the Object if you see, and
begin CPR.
2)If you are alone with a choking unresponsive child , open the Airway, Remove FB if
you see ,
begin CPR after about 5 cycle or 2 min you can activate EMS.
3)Either in Adult or Children if you see the FB while opening the airway for breathing
remove it
with your fingers and then assess for the response if no response continue CPR.
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* Sequence of actions after Relief of Choking
1.Feel air movement and see the chest rise when you give
breaths.
2.See and remove the Foreign Body (FB) from the victims
pharynx.
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Follow the steps after relieving choking in unresponsive victim
Step
Action
Provide 2 Breaths
Check for Pulse ;
1- if No Pulse & No Breathing ------ perform CPR & attach to AED
2- if there is Pulse but No Breathing------- Breathing every 5-6 sec & check
for Pulse every 2 min
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Follow the steps after relieving choking in unresponsive victim
Step
Action
Check for Pulse;
3- if there is Pulse & victim is Breathing----- put the victim in the recovery
position
If you successfully removed the FB by Abdominal Thrust. Advice the

patient to seek medical advice and ensure that the patient does not have a
complication from Abdominal Thrust
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Relieving Choking in Infant
Recognizing Choking in the Responsive Infant
Rescue Action
- Good air exchange

- Responsive and can cough forcefully
- May wheeze between coughs
- Do not interfere with the victims own

attempt to expel FB but stay and
monitor her or his condition
- If mild airway obstruction persists

activate EMS
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Recognizing Choking in the Responsive Infant
Severe Airway Obstruction signs
Rescuer Action
Poor or no air Exchange

Weak, ineffective cough or no cough
at all
High pitched noise while inhaling or
no noise at all
Increase respiratory difficulty
Possible cyanosis
Unable to cry
Unable to move air
If the victim can not make any noise or

sounds or can nor breath. You have to
activate EMS
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Relieving Choking in the Responsive Infant
Step
Action
Kneel or set with infant in your lap
If it is easy to do bare the infants chest
Hold the infant prone with the head slightly lower than the chest, resting
on your forearm.
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Step
Action
Support the infants head & jaw with your hand. Take care to avoid
compressing the soft tissues of the infants throat. Rest your forearm on your
lap or thigh to support the infant.
Deliver up to 5 back slaps forcefully in the middle of the back between the
infants shoulder blades, using the heel of your hand. Deliver each slap with
sufficient force to attempt to dislodge the foreign body.
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Step
Action
After delivering up to 5 back slaps, place your free hand on the infants back,
supporting the back of the infants head with palm of your hand.
The infant will be adequately cradled between your 2 forearms, with the
palm of one hand supporting the face & jaw while the palm of the other
hand supports the back of the infants head.
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Step
Action
Turn the infant as a unit while carefully supporting the head & neck. Hold the
infant on his back with your forearm resting on your thigh. Keep the infants
head lower than the trunk.
Provide up to 5 quick downward chest thrusts in the same location as chest

compressions just below the nipple line. Deliver chest thrusts at a rate of
about 1 per second, each with the intention of creating enough of an
artificial cough to dislodge the foreign body.
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Relieving Chocking in the Responsive Infant
Step
Action
Repeat the sequence of up to 5 back slaps and up to 5 chest thrusts until the
object is removed or the infant becomes unresponsive.
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Relieving Chocking in the Unresponsive Infant
Step
Action
Place the infant on a firm, flat surface.
Open the infants airway & look for an object in the pharynx. If an object is
visible, remove it. Do not perform a blind finger sweep.
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Relieving Chocking in the Unresponsive Infant
Step
Action
Begin CPR with 1 extra step: each time you open the airway, look for the
obstructing object in the back of the throat. If you see an object, remove it.
After approximately 5 cycles (about 2 minutes) of CPR, activate the

emergency response system.
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Part (6)
Automated External Defibrillator (AED)
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The most common rhythm is Ventricular Fibrillation (VF).

The most effective treatment for VF is Electrical defibrillation.
The probability of successful defibrillation decreases over time.
VF deteriorates to Asystole if not treated.
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Common Steps to Operate all AEDs
Steps
Action
Power ON the AED.

Open the carrying case or the top of the AED.
Turn the power on.
Attach electrode pads to the victims bare chest.

Choose correct pads (adult VS children) for size/ age of victim. Use child
pads or child system for children less than 8 years of age if available. Do not
use child pads or child system for victims 8 years and older.
Peel the backing away from the electrode pads.
Quickly wipe the victims chest if it is covered with water or sweat.
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Steps
Action
Attach the adhesive electrode pads to the victims bare chest.
- Place one electrode pad on the upper right side of the bare chest to the
right of the breastbone, directly below the collarbone.
-Place the other pad to the left of the nipple, a few inches below the left
armpit.
Attach the AED connecting cables to the AED box.
Clear the victim & analyze the rhythm.

Always clear the victim during analysis. Be sure that no one is touching the
victim, not even the person in charge of giving breaths.
Some AEDs will tell you to push a button to allow the AED to begin
analyzing the heart rhythm. It may take about 5 to 15 seconds to analyze.
The AED then tells you if a shock is needed.
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Steps
Action
If the AED advises a shock, it will tell you to be sure to clear the victim.
Clear the victim before delivering the shock: be sure no one is touching
the victim to avoid injury to rescuers.
- Loudly state a clear the patient message such as Im clear, youre clear,
everybodys clear or simply clear.
- Perform a visual check to ensure that no one is in contact with the victim.
Press the SHOCK button.

The shock will produce a sudden contraction of the victims muscles.
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Steps
Action
As soon as the AED gives the shock, begin CPR starting with chest
compressions.
After 2 minutes of CPR, the AED will prompt you to repeat steps 3 and 4.
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THANK YOU
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