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BASIC LIFE SUPPORT: HEALTHCARE

PROVIDER
INTRODUCTION
Optimal patient care requires that the EMT-I be proficient in Basic Life Support according to American Heart Association (AHA) Healthcare Provider (HCP) standards, as well as be able to identify situations in which CPR can be withheld according to L.A. County guidelines. The following topics will be discussed during this lesson:

Chain of Survival and the Role of the Healthcare Provider Clinical Presentations and Treatment of Heart Disease and Stroke Prudent Heart Living Techniques for Adult and Pediatric CPR and Use of the AED Pathophysiology, Treatment and Prevention of Foreign Body Airway Obstruction Injury Prevention in the Pediatric Age Group L.A. County guidelines for withholding CPR

LESSON OBJECTIVES
At the end of this lesson the participants will be able to: 1. Describe the links in the AHA Chain of Survival, including the importance of: Activating the appropriate emergency response system (phoning 911 or other response system) Performing CPR Using a barrier device Providing bag-mask ventilation Providing early defibrillation Ensuring the arrival of early advanced care by activating the appropriate emergency response system (phoning 911 or other response system) Describe the steps of CPR: When to start CPR When to start rescue breathing, including ventilation with a barrier device and bagmask ventilation (with and without oxygen) How to check for normal breathing or signs of circulation The ABC sequence of CPR When and how to use an AED The signs of severe or complete FBAO How to relieve FBAO in the responsive and unresponsive victim Describe the signs of 5 major emergencies in adults Heart attack Stroke Cardiac arrest

2.

3.

Respiratory arrest FBAO 4. Describe strategies to prevent sudden infant death syndrome in infants and injuries in children.

5.

Using an adult, child, or infant manikin, demonstrate the following skills: Activation of the emergency response system (phone 911 or other appropriate response system) Rescue breathing using mouth-to mouth and bag-mask ventilation (with and without oxygen) for adult, child, and infant victims 1- and 2-rescuer CPR for adult, child, and infant victims Use of an AED for victims 8 years of age (and approximately 25 kg or more) Relief of FBAO in the responsive and unresponsive victim of any age

SKILLS
One Rescuer: Adult, Child, and Infant CPR Two Rescuer: Adult CPR FBAO Conscious and Unconscious: Adult, Child, and Infant Bag-mask ventilation

KEY VOCABULARY
The following terms will be used during this lesson:

Adult Greater than eight years of age Child - One year to eight years of age Infant - Less than one year of age Prudent Heat Living a lifestyle that minimizes the risk of future heart disease. Epigastrium - upper mid-portion of abdomen Nitroglycerin - a medication that acts by dilating the coronary arteries, which increases blood flow to the heart muscle; and lowering the blood pressure and dilating the veins, which decreases the work of the heart and the heart muscle's need for oxygen. Ventricular Fibrillation - a chaotic, uncoordinated quivering of the heart muscle, producing no heartbeat Pneumothorax - collapsed lung Hemothorax - blood in the pleural cavity

Fat Emboli - fat bubbles or particles circulating in blood stream as a result of long bone fractures

KEY CONCEPTS
The following section provides information and space for taking notes on the key concepts discussed by the instructor. American Heart Association Statistics

Cardiovascular disease is the leading cause of death in the U.S. Cardiovascular disease accounts for nearly one million deaths per year in the U.S. Approximately million deaths are due to acute myocardial infarction; approximately 50% of these deaths are sudden and occur within the first hour of the onset of symptoms Stroke is the third leading cause of death in the U.S. and the leading cause of brain injury in adults Approximately million suffer a stroke and nearly of these die annually

Emergency Cardiovascular Care (ECC)

Includes all responses (prehospital and in-hospital) needed to stabilize the victim or patient who develops life-threatening events affecting the respiratory, cardiovascular, and cerebrovascular systems Ultimate goal is to maximize the outcome for all victim or patients Two components of ECC are BLS and ACLS

Basic Life Support (BLS)

Includes interventions that can rapidly be performed by trained laypersons and healthcare providers to ensure recognition of common emergencies, access to ACLS, adequate airway, breathing, and oxygenation, and adequate circulation BLS skills include CPR, use of AED, and relief of foreign body airway obstruction

Advanced Cardiac Life Support Includes BLS plus the use of adjunctive equipment to support ventilation, establishment of IV access, administration of drugs, use of cardiac monitoring, defibrillation or other control of arrhythmias, and care after resuscitation

CHAIN OF SURVIVAL

Early Access Early CPR Early Defibrillation Early Advanced Care

First Link: Early Access

Problem: Long 911 call-to-defibrillation intervals are common Key to effectiveness of this link: Recognition of early warning signs such as chest pain and shortness of breath so that 911 is called before collapse occurs Early identification of collapse can lead to rapid activation of the EMS system, rapid dispatching and arrival of first responders who can bring defibrillation and ACLS capabilities to the patients side

Second Link: Early CPR

CPR is most effective when started immediately after collapse Bystander CPR has been consistently shown to have a significant positive effect on survival Bystander CPR is the best treatment that a cardiac arrest patient can receive until the arrival of defibrillation and ACLS care

Third Link: Early Defibrillation

The link most likely to improve survival rates Time to defibrillation is the critical variable for successful conversion from VF to a normal rhythm Every minute that passes can reduce the chance for successful conversion by 7-10% Goal of early defibrillation: Within 5 minutes of EMS call receipt to shock

Fourth Link: Early Advanced Care

Designed to prevent cardiac arrest through the use of advanced airway management, administration of medication, and other interventions Include therapies that help resuscitate victims of cardiac arrest who are not responding to defibrillation Can provide defibrillation if VF develops and helps stabilize the patient after resuscitation

EARLY RECOGNITION OF MAJOR EMERGENCIES CORONARY ARTERY DISEASE (CAD) Clinical Presentation of Angina Pectoris Angina Pectoris a common symptom of CAD; a transient pain or discomfort caused by an inadequate blood flow and oxygen delivery to the heart muscle Character: Described as crushing, pressing, constricting, oppressive, or heavy Location: Located behind sternum or throughout front of chest; may radiate to shoulders, arms, neck, jaw, back of chest and upper abdomen Duration: Steady discomfort, usually lasting <15 minutes

Provoking Factors: Any factor that increases myocardial oxygen demand beyond available supply, such as increased heart rate and increased

blood pressure Relieving Factors: Reversal of provoking factors Rest Nitroglycerin

Unstable Angina Angina that: Occurs at rest Wakes that patient at night Lasts longer than 20 minutes

Atypical Presentations of CAD Women, the elderly, and diabetic patients may have severe CAD but present without classic signs and symptoms

Symptoms of weakness, shortness of breath, syncope, or light headedness may be the only symptoms in diabetic patients

Clinical Presentation of AMI (or Heart Attack) AMI occurs when an area of the heart muscle is deprived of blood flow and oxygen for a prolonged period (usually more than 20-30 minutes) and the muscle begins to die

Character, location and duration of chest pain or discomfort is similar to angina; usually described as more intense, however, this is not universal Other Accompanying Signs or Symptoms Sweating, nausea, vomiting, shortness of breath or weakness.

Provoking Factors Most episodes occur at rest or with modest daily activity Heavy physical exertion (occurs infrequently) Other factors include emotional stress and illicit drug use (i.e., cocaine) Relieving Factors

Not usually relieved with rest and/or nitroglycerin

A victim's most common reaction to a heart attack is denial.

Actions for Survival (According to American Heart Association) Person with unknown CAD

Recognize the signals of a heart attack Stop activity and sit or lie down Wait about 5 minutes to see if the symptoms go away If pain persists, activate EMS If no EMS available, take victim to the nearest 24hr hospital emergency department.

Person with known CAD (using nitroglycerin):

Recognize the signals of a heart attack Stop activity and sit or lie down Take 1 nitroglycerin tablet at a time at 3-5 minute intervals (maximum 3 tablets) If pain persists, activate EMS If no EMS available, take victim to the nearest 24hr hospital emergency department.

Sudden Cardiac Death (Cardiac Arrest) Sudden Death occurs when the heart stops beating and breathing ceases abruptly or unexpectedly

May occur as the initial and only manifestation of CAD Most commonly occurs within one or two hours after the onset of a heart attack Most common cause is CAD Directly caused by ventricular fibrillation, which results in the

lack of an effective heart beat Best chance for survival: early CPR and early defibrillation

RISK FACTORS AND PRUDENT HEART LIVING Risk Factors of CAD Factors that cannot be changed:

Heredity Male gender Race

Factors that can be changed:

Cigarette smoking High blood pressure High blood cholesterol levels Physical inactivity Diabetes Obesity Excessive Stress

Prudent Heart Living

Weight control Physical fitness Sensible dietary habits Avoidance of cigarette smoking Reduction of cholesterol and triglycerides in diet Control of high blood pressure Control of Diabetes Eliminate obesity

CEREBROVASCULAR DISEASE Stroke The third leading cause of death in the U.S. Caused by occlusion (ischemic stroke) or rupture (hemorrhagic stroke) of a blood vessel Transient ischemic attack (TIA) produces signs identical to those of a stroke, but they last only a few minutes; indicates a future risk

of stroke Early detection of signs and symptoms, rapid transport and hospital triage is necessary in order to initiate timely therapies

New Therapies

Effective in restoring blood flow and oxygen to the brain May improve outcome and limit neurological insult To be effective, they must be initiated within 3 hours of the onset of the stroke symptoms

Risk Factors Specific to Stroke Transient ischemic attacks (TIAs) High red blood cell count Heart disease Chain of Survival and Recovery Early recognition and activation of EMS EMS response, treatment and transport Notification of stroke center Early emergency department care Signs of Stroke or TIA Sudden weakness or numbness of the face, arm or leg on one side of the body Loss of speech, slurred or incoherent speech Unexplained dizziness, unsteadiness or sudden falls Dimness or loss of vision, particularly in one eye Altered level of consciousness Unusually severe or sudden intense headache General Emergency Therapy Maintain airway patency Basic airway maneuvers, airway adjuncts and suction may be necessary Endotracheal intubation if basic airway maneuvers are unsuccessful Positive-pressure ventilation if inadequate respirations or respiratory arrest

Monitor patient for seizures and treat appropriately

CARDIOPULMONARY RESUSCITATION Indications for CPR

Cardiac arrest Respiratory arrest Only exceptions:

L.A. County Reference #814 Determination/Pronouncement of Death in the Field L.A. County Reference #815 Honoring Prehospital DoNot-Resuscitate (DNR) Orders

Use of Automated External Defibrillator (AED) AEDs are considered an important and lifesaving addition to BLS AEDs are included in the sequence of BLS (to be taught in a separate lecture) The Sequence of BLS Establish Unresponsiveness If head or neck trauma suspected, limit movement or log-roll **If no response, activate EMS system by phoning 911 or other emergency response number **Activate EMS system Adult: After determining the victim is unresponsive, exception near-drowning, traumatic arrests, & drug overdoses (activate EMS after 1 minute of CPR) Child & Infant: Not done until after 1 minute of CPR, exception children known to be high risk for cardiac arrest (activate EMS immediately after collapse)

Open Airway Victim should be supine Open airway with head tilt-chin lift maneuver Use jaw-thrust maneuver if head or neck trauma suspected Assess Breathing (10 seconds) Look for chest rise and fall Listen for air escaping during exhalation Feel for the flow of air Recovery Position Used if victim unresponsive, but breathing with signs of circulation A modified lateral position used to prevent the airway from being obstructed by the tongue, mucus or vomitus Provide Rescue Breathing Required if breathing is absent or inadequate Give 2 slow breaths using the lowest tidal volume sufficient to make the chest rise: Adult: Over 2 seconds Child & Infant: Over 1 1 seconds

Rescue Breathing Techniques: Mouth-to-Mouth Mouth-to-Nose Mouth-to-Stoma Mouth-to-Barrier Mouth-to-Face Shield Mouth-to Mask * Bag-mask device * *If oxygen available, use smaller tidal volumes over 1-2 seconds. If no oxygen available, use slighter higher tidal volumes over 2 seconds. May use the lateral or cephalic techniques.

Cricoid Pressure Pressure applied to the victims cricoid cartilage in order to compress the esophagus between the trachea and the spine; effective in preventing gastric inflation

Assess for Circulation (10 seconds) Adult & Child: Palpate carotid pulse Infant: Palpate brachial pulse If pulse present but no breathing, provide rescue breathing at a rate of: Adult - 1 breath every 4-5 seconds (or 10-12/minute) Child & Infant 1 breath every 3 seconds (or 20/minute)

Chest Compressions Adult: Required if no pulse present Child & Infant: Required if no pulse present or HR less than 60 bpm

Compression Rate: Adult, Child, & Infant 100/min Compression to Ventilation Ratio: Adult 1- and 2-rescuer CPR 15:2 Infant and child 1- and 2-rescuer CPR 5:1 Proper Hand Placement Adult: Place hands on the sternum between the nipple line Child: Place heel of one hand over lower half of sternum Infant: Place 2 fingers of one hand one fingers width below the nipple line or two-thumb encircling hands technique over the lower half of sternum Depth of Compression Adult: 1 - 2 inches or enough to generate a pulse Child & Infant: 1/3 the depth of the chest or enough to generate a pulse

Adult: Perform 4 complete cycles 15 compressions and 2 ventilations, then recheck for signs of breathing and circulation Child & Infant: Perform 20 cycles of 5 compressions and 1 ventilation, activate EMS, then recheck for signs of breathing and circulation Reassessment (10 seconds) Should be performed after the first minute of CPR and every few minutes thereafter If no pulse, resume CPR beginning with chest compressions If pulse and breathing present, place in recovery position If pulse present but no breathing, provide rescue breathing:

Adult - 1 breath every 4-5 seconds (or 10-12/minute) Child & Infant 1 breath every 3 seconds (or 20/minute)

2-Rescuer CPR Refer to skills sheet Monitoring the Effectiveness of CPR

Chest rise with ventilation Carotid or brachial pulse with compression Rib fractures Gastric inflation, with or without regurgitation Lacerated spleen and liver Fractured sternum Pneumothorax Hemothorax Lung contusion Fat emboli

Complications of CPR

Minimizing Complications Some of the complications may be minimized by performing CPR properly, such as using proper hand placement, however, they cannot be entirely prevented

Gastric inflation can be minimized by maintaining an open airway and limiting ventilation volumes to the point at which the chest rises adequately

Unique Situations

CPR should not be interrupted except for endotracheal intubation, when AED being applied/used, or transporting problems Interruptions, if necessary, should be brief and must be avoided if possible If the rescuer is alone, a momentary delay may be necessary to activate EMS

CARDIOPULMONARY ARREST IN INFANTS AND CHILDREN

Cardiac arrest in children typically represents the terminal event of progressive shock or respiratory failure Common Causes Injuries Foreign-body airway obstruction Smoke inhalation Sudden infant death syndrome (SIDS) Poisoning Infections of throat and respiratory tract Congenital heart defect Common Childhood Injuries

Motor vehicle injuries Pedestrian Injuries Bicycle injuries Submersion Burns Firearm injuries

Injury Prevention

Injury is the leading cause of death in children and young adults Prevention of these injuries would substantially reduce childhood deaths and disability

SIDS Prevention SIDS typically occurs in infants 1 month to 1 year Increased risks associated with many factors including: prone sleeping position, the winter months, lower family income, males, siblings of SIDS victims To reduce the risk of SIDS: Place infants supine when sleeping Infants placed on their side should be supported to keep them from rolling to the prone position Do not place infants on soft surfaces to sleep FOREIGN BODY AIRWAY OBSTRUCTION Causes of obstruction Common causes: Adults

Food, especially meat Attempting to swallow poorly chewed food associated with high blood alcohol levels and dentures Toys Balloons Small objects

Children

Food (hot dogs, nuts, candies, grapes) Signs and Symptoms of Obstruction Partial Airway Obstruction Universal distress signal Good air exchange - forceful cough, may have wheezing between coughs Poor air exchange - weak, ineffective cough, highpitched sounds, increased respiratory difficulty and possibly cyanosis Complete Airway Obstruction Universal distress signal Unable to speak, breathe or cough Progresses to unconsciousness Cyanosis Management of Partial Airway Obstructed

Good air exchange - encourage patient to continue coughing until condition progresses to poor air exchange or complete airway obstruction Poor air exchange - manage like complete airway obstruction

Management of Complete Airway Obstruction (Refer to AHA's BLS Performance Sheets for the following) Adult

Conscious Adult Abdominal thrusts, repeat multiple times as necessary

Unconscious Adult Attempt to ventilate, if unsuccessful, reposition head and reattempt 5 abdominal thrusts

Attempt to visualize foreign object and remove-blind finger sweep permitted Attempt to ventilate Repeat entire sequence

Chest thrusts are recommended for patients in advanced pregnancy or those who are markedly obese

Child

Conscious Child Abdominal thrusts, repeat multiple times as necessary Unconscious Child Attempt to ventilate, if unsuccessful, reposition head and reattempt 5 abdominal thrusts Attempt to visualize foreign object and remove - NO blind finger sweeps Attempt to ventilate Repeat entire sequence

Infant

Conscious Infant 5 back blows and 5 chest thrusts, repeat series until successful Unconscious Infant Attempt to ventilate, if unsuccessful reposition head and reattempt 5 back blows and 5 chest thrusts Attempt to visualize foreign object and remove - NO blind finger sweeps Attempts and reattempts to ventilate Repeat entire sequence until successful

Note: Managing FBAO for victims who are initially conscious and then become unconscious follow a different sequence. Refer to skills sheet. AHA'S GUIDELINES FOR BLS BREATHING AGE VENTS/MIN DURATION

Adult Child Infant

10-12/min 20/min 20/min

1-2 sec/breath 1-1 sec/breath 1-1 sec/breath

CPR Adult Ratio Rate Depth Hand Placement Child (1-8 years) Ratio Rate Depth 15:2 (One- and two- rescuer) 100/min 1-2 inches to generate a palpable pulse Hands on sternum between the nipple line

5:1 100/min 1/3-1/2 depth of chest to generate a palpable pulse Hand Placement Heel of one hand over lower of sternum

Infant (less than 1 year) Ratio 5:1 Rate at least 100/min Depth 1/3-1/2 depth of chest to generate a palpable pulse Hand Placement 2 fingers one fingers width below the nipple line; or 2 thumbs encircling hands technique RECOVERY POSITION Roll patient laterally to prevent aspiration only if trauma not suspected EMS ACTIVATION Age Over 8 years Activate EMS after assessing unresponsiveness Up to 8 years Activate EMS after 1 min of CPR Note: There are exceptions to this guideline.