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BLS for HCP

BASIC LIFE SUPPORT


(Based on AHA 2010 Guidelines)

SL.ppt/TR/FC 1 1
Course Overview

Basic Life Support


Legal Bases

• Policy: A.O. 155 s. 2004


“Basic Life Support Training is mandatory
to all health workers”

• HEMS Goal:
“At least one member of each household
shall be trained in BLS”

DOH - HEMS Basic Life Support Training of Trainers


Types of BLS Training Courses:
A. Basic
1. BLS Training for Healthcare Providers
2. BLS Training for Lay Rescuers
B. Training of Trainers

DOH - HEMS Basic Life Support Training of Trainers


Healthcare Provider
• Medical
• Allied-medical professionals

DOH - HEMS Basic Life Support Training of Trainers


Lay Rescuer
• Non-medical personnel
• Provided that they can understand the
medium of instruction
• Able to perform the skills requirement

DOH - HEMS Basic Life Support Training of Trainers


Course Objectives:
At the end of the training, participants will be
able to acquire knowledge, attitude , and
skills necessary in an emergency to help
sustain life and minimize the consequences
of respiratory and cardiac emergencies until
more advanced medical help arrives.

DOH - HEMS Basic Life Support Training of Trainers


Specific Objectives
• Describe the principles of Emergency
Care.
• Identify the three kinds of life support,
• Five links of survival for adult and
pediatric patients; and
• Discuss the human anatomy and
physiology of the nervous, respiratory and
circulatory systems.

DOH - HEMS Basic Life Support Training of


• Demonstrate how to provide cardiopulmonary
resuscitation to an adult, child & infant.

• Demonstrate how to provide rescue breathing


(for health care provider only) alone for an adult,
child & infant who show signs of circulation but
have inadequate or not breathing.

DOH - HEMS Basic Life Support Training of Trainers


• Discuss the indications, proper use and
maintenance of Automated External Defibrillator
(AED).

• Demonstrate how to provide abdominal thrust to


conscious adult; chest thrust and backslaps to
conscious infant; and chest thrust to unconscious
adult, child and infant with obstructed airway.

DOH - HEMS Basic Life Support Training of Trainers


Scope and limitation:
a. Scope
• Six sessions including RB for Health Care
Providers / Five Sessions without RB for Lay
Rescuers
• Skills Demonstration
• Skills Practice & Evaluation
b. Limitation
Those who are not physically fit &
pregnant are not allowed to join.

DOH - HEMS Basic Life Support Training of Trainers


BLSSession
for HCP1
Principles of Emergency Care

SL.ppt/TR/FC 20 12
At the end of this session, participants shall be able to:

1. Explain the procedure of getting started during emergency.


2. Describe the five emergency action principles .
3. Enumerate golden rules in giving emergency care.
4. Demonstrate how to do initial assessment of the victim.
5. Discuss the basic precautions in disease prevention.
1. PLANNING
Emergency plan should be established
based on anticipated needs and available
resources.

2. PROVISION OF LOGISTICS
The emergency response begins with the
preparation of equipment and personnel before
any emergency occurs.

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3. INITIAL RESPONSE
a. Ask for HELP.
b. Intervene
c. Do no further harm.

4. INSTRUCTION TO BY-STANDERS
Proper information and instruction to by-
stander/s would provide organized first
aid care.

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1. SURVEY THE SCENE
2. ACTIVATE MEDICAL ASSISTANCE
3. INITIAL ASSESSMENT OF THE VICTIM
4. SECONDARY ASSESSMENT OF THE VICTIM
5. REFERRAL FOR FURTHER EVALUATION AND MANAGEMENT

SL.ppt/TR/FC4
1. SURVEY THE SCENE
Once you recognized that an emergency has occurred and decide to act, you must make
sure the scene of the emergency is safe for you, the victim/s, and any bystander/s.

Elements of the Survey the Scene

• Scene safety.
• Mechanism of injury or nature of illness.
• Determine the number of patients and
additional resources.

SL.ppt/TR/FC5
2. ACTIVATE MEDICAL ASSISTANCE (AMA)
OR TRANSFER FACILITY
In some emergency, you will have enough time to call for specific medical advice before
administering first aid. But in some situations, you will need to attend to the victim first.

Call First and Care First


Both trained and untrained bystanders should be
instructed to Activate Medical Assistance as soon as
they have determined that an adult victim requires
emergency care “Call First”. While for infants and
children a “Care First” approach is recommended.

SL.ppt/TR/FC6
Information to be remembered in activating Medical Assistance:

-WHAT happened?
-LOCATION?
-NUMBER of Persons Injured?
-EXTENT of Injury and First Aid given?
-The TELEPHONE no. from where you are calling?
-PERSON who activated Medical Assistance must identify him/herself and drop
the phone last….

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WHAT ARE YOUR
EMERGENCY NUMBERS?

HEMS Operation Center


711-1001

711-1002

651 7800 loc 2206/2207

EMERGENCY HOTLINES

117 – DILG PATROL


168 – MAKATI C3 RESCUE
161 – MARIKINA RESCUE
136 – MMDA
9284396 – QUEZON CITY RESCUE – SAGIP BUHAY
9275914
6411000 – PASIG CITY RESCUE
8338512 – PASAY CITY RESCUE
5270864 – PNRC ( Manila chapter)

SL.ppt/TR/FC8
For sudden collapse in victim of all ages, the lone HCP should

* call the emergency response number( e.g.161, 117, 168 or


nearest hospital )
* use an AED, when readily available
* return to the victim to begin CPR (and use the AED )

For unresponsive victim of all ages with likely asphyxial arrest (e.g.
drowning) the HCP should

* deliver at least 5 cycles (2 min.) of CPR before leaving


the victim
* call the emergency response number
* use an AED, if available

SL.ppt/TR/FC9
3. DO A PRIMARY SURVEY OF THE VICTIM
In every emergency situation, you must first find out if there are conditions that are an
immediate threat to the victim’s life.

Perform Compression
Check for Responsiveness

Perform Rescue Breathing Open the Airway 22

SL.ppt/TR/FC10
4. DO A SECONDARY ASSESMENT OF THE VICTIM
It is a systematic method of gathering additional information about injuries or
conditions that may need care.
a. Interview the victim
S- signs and symptoms
A - allergies
M - medications
P - past medical history
L - last meal taken
E - events prior to injury or incident

b. Check vital signs- every 15 minutes if stable condition, and


every 5 minutes if unstable

SL.ppt/TR/FC11
c. Head to toe examination

D- deformity
C- contusion
A- abrasion
P- punctures
B- burn
T- tenderness
L- laceration
S- swelling
SL.ppt/TR/FC12
5. REFERRAL OF THE VICTIM FOR FURTHER
EVALUATION AND MANAGEMENT
It refers to the transfer of a victim to hospital or health
care facility if necessary for a definitive treatment.

SL.ppt/TR/FC13
1. Do obtain consent when possible
2. Do think of the worst
3. Do remember to identify yourself
4. Do provide comfort and emotional support
5. Do respect the victim( modesty and privacy)
DO’s 6. Do be as calm and direct as possible
7. Do care for the most serious injuries first
8. Do assist the victim on medication
9. Do keep on lookers away from the injured
person
10. Do handle the victim to a minimum
11. Do loosen tight clothing

SL.ppt/TR/FC14
1. Do not let the victim see his/her injuries
2. Do not leave the victim alone except to
get help
DON’TS 3. Do not assume that the victim’s obvious
injuries are the only one
4. Do not make any unrealistic promises
5. Do not trust the judgment of a confused
person

SL.ppt/TR/FC15
BODY SUBSTANCE ISOLATION (BSI)
Are precautions taken to isolate or prevent risk
of exposure from any other type of bodily substance
using personal protective equipment (PPE).

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Basic Precautions and Practices

1. Personal Hygiene 2. Protective Equipment 3. Equipment Cleaning


& Disinfecting

SL.ppt/TR/FC 28 29
Were we able to:

1. Explain the procedure of getting started during


emergency.
2. Describe the five emergency action principles .
3. Enumerate golden rules in giving emergency care.
4. Demonstrate how to do initial assessment of the
victim.
5. Discuss the basic precautions in disease prevention.
BLSSession
for HCP2
Introduction to
Basic Life Support

SL.ppt/TR/FC 20 31
OBJECTIVES:

At the end of this session, participants shall be able


to:
1. Explain the concept of the session.
2. Identify the three kinds of Life Support.
3. Identify the five links in the Chain of Survival for
Adult and Pediatric patients.
4. Identify the anatomical positions, directions,
locations and regions of the human body.

SL.ppt/TR/FC 2 32
Module 2: Introduction to B L S
Con’t of OBJECTIVES:

5. Discuss the anatomy and physiology of the


respiratory, circulatory, and nervous systems.
6. Discuss the Medical Conditions for applying Basic
Life Support

SL.ppt/TR/FC 3 33
THREE KINDS OF LIFE SUPPORT

1. BASIC LIFE SUPPORT (BLS)


A set of emergency procedures that consist of recognizing
respiratory or cardiac arrest and the proper application of
Cardio-Pulmonary Resuscitation (CPR) with or w/o
Automated External Defibrillation (AED) or Foreign Body
Airway Obstruction Management (FBAOM) and Rescue
Breathing (RB) or to maintain life until a victim recovers or
advanced life support is available.

SL.ppt/TR/FC 5 34
THREE KINDS OF LIFE SUPPORT

2. ADVANCED CARDIAC LIFE SUPPORT (ACLS)


A set of clinical interventions for the urgent treatment of
cardiac arrest and other life threatening emergencies, as well
as the knowledge and skills to deploy those interventions.

3. PROLONGED LIFE SUPPORT (PLS)


For post resuscitative and long term resuscitation with the
use of adjunctive equipment such as ventilator, cardiac
monitor, pulse oximeter etc.

SL.ppt/TR/FC 6 35
INTRODUCTION TO BASIC LIFE SUPPORT
• Basic life support (BLS) is the foundation for
saving lives following cardiac arrest

• Fundamental aspects of BLS

- immediate recognition of sudden cardiac arrest (SCA) and


activation of the emergency response system

- early cardiopulmonary resuscitation (CPR)

- and rapid defibrillation with an automated external


defibrillator (AED).

SL.ppt/TR/FC 6 36
Adult Chain of Survival

Recognition Early Rapid Effective Integrated


Activation CPR Defibrillation ACLS Post-cardiac
Care

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1. The First Link: IMMEDIATE RECOGNITION & ACTIVATION OF EMS

It is the event initiated after the patient’s collapse until the arrival of Emergency
Medical Services personnel prepared to provide care.

2. The Second Link: EARLY CPR


It is most effective when started immediately after the victim’s collapse. The
probability of survival approximately doubles when it is initiated before the
arrival of EMS.

SL.ppt/TR/FC 8 38
3. The Third Link: RAPID DEFIBRILLATION
It is the cornerstone therapy for patients who have just suddenly
collapsed probably due to ventricular fibrillation and pulse-less
ventricular tachycardia.

4. The Fourth Link: EFFECTIVE ACLS


Provided by highly trained personnel like paramedics.

5. The Fifth Link: INTEGRATED POST-CARDIAC ARREST CARE


Post cardiac arrest care after return of spontaneous circulation (ROSC)
can improve the likelihood of patient survival with good quality of life.

SL.ppt/TR/FC 8 39
ANATOMICAL TERMS
(Position, direction and location of a body part)

1. Anatomical position 9. Lateral


2. Superior 10. Internal
3. Inferior 11. External
4. Proximal 12. Superficial
5. Distal 13. Deep
6. Anterior 14. Supine position
7. Posterior 15. Prone position
8. Medial 16. Lateral recumbent

SL.ppt/TR/FC 12 40
ANATOMICAL TERMS
(Position, direction and location)

Supine Position Prone Position

Lateral Recumbent/ Recovery Position

SL.ppt/TR/FC 13 41
BODY REGIONS
1. Cranial Cavity 4. Abdominal Cavity
• Brain • Liver • Stomach
• Pancreas • Kidney
• Intestines • Spleen
2. Spinal Cavity
• Spinal Cord
5. Pelvic Cavity
3. Thoracic Cavity • Bladder
• Lungs • Rectum
• Heart • Reproductive organs

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Systems of the Human Body:
* Respiratory System
* Circulatory System
* Nervous System
* Integumentary System
* Digestive System
* Excretory System
* Reproductive System
* Musculo-skeletal System

SL.ppt/TR/FC 16 43
BODY SYSTEMS

1. Nervous System 2. Respiratory System 3. Circulatory System

4. Digestive System 5. Urinary System 6. Reproductive System

7. Musculo-Skeletal System 8. The Skin

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BODY SYSTEMS
• DIGESTIVE SYSTEM - is the system that absorb food
and eliminate some waste products.
Parts: Mouth , Salivary Glands, Pharynx, Esophagus,
Liver, Gallbladder, Pancreas, Rectum

• URINARY SYSTEM - is the system that removes waste


products.
Parts : Kidney, Ureters, Urinary Bladder, Urethra

SL.ppt/TR/FC 18 45
RESPIRATORY SYSTEM
Diaphragm is the thin layer of muscle that separates the chest cavity containing the lungs and
heart from the abdominal cavity containing the intestines and digestive organs.
Trachea (windpipe ) is a tube extending from below the voice box into the chest where it splits
into two branches, the bronchi, that lead to each lung.

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SL.ppt/TR/FC 20
DIGESTIVE
SYSTEM

SL.ppt/TR/FC 20 47
REPRODUCTIVE SYSTEM – is the system
that propagates species.

Parts:
Male Female
- Testicles - Ovary
- Vas deferens - Fallopian tubes
- Seminal vesicle - Uterus
- Prostate gland - Vagina
- Urethra
- Penis

SL.ppt/TR/FC 19 48
BODY SYSTEMS
• MUSCULO-SKELETAL SYSTEM- is the system
that gives form to the body, allow bodily
movement, provide protection to the vital internal
organs, produce red blood cells and serves as a
reservoir of calcium, phosphorus and other
important body chemicals.
• SKIN – is the system that controls body
temperature and appreciate sensation.
Parts : Superficial epidermis, Deeper dermis

SL.ppt/TR/FC 20 49
ANATOMY AND PHYSIOLOGY

1. The Respiratory System


It delivers oxygen to the body, as
well as removes carbon dioxide
from the body. The passage of air
into and out of the lungs is called
respiration. Breathing in is called
inspiration or inhalation. Breathing
out is called expiration or
exhalation.

SL.ppt/TR/FC 21 50
ANATOMY AND PHYSIOLOGY

• Air that enters the lungs contains:


– 21% O2
– trace of CO2
Breathing
• Air exhaled from the lungs contains:
– 16% O2
– 4% CO2

SL.ppt/TR/FC 22 51
Superior vena cava
(oxygen-poor blood
from head and upper
body

ANATOMY AND PHYSIOLOGY

2. The Circulatory System


It delivers oxygen and
nutrients to the body’s
Left pulmonary
tissues and removes waste Right pulmonary
artery (blood to
vein

products. It consists of the right lung)

heart, blood vessels, and Right atrium

blood.
Right ventricle

Inferior vena cava


(oxygen-poor blood
from lower body

SL.ppt/TR/FC 23 52
ANATOMY AND PHYSIOLOGY

Circulation

SL.ppt/TR/FC 24 53
ANATOMY AND PHYSIOLOGY

*Clinical death
0 - 1 min. - cardiac irritability
1 - 4 min. - brain damaged not likely
4 - 6 min. - brain damage possible

*Biological death
6 - 10 min. - brain damaged very likely
over 10 min. - irreversible brain damaged

SL.ppt/TR/FC 25 54
ANATOMY AND PHYSIOLOGY

3. The Nervous System

It is composed of the brain, spinal cord and


nerves. It has two major functions –
communication and control. It lets a person be
aware of and react to the environment. It
coordinates the body’s responses to stimuli and
keeps body systems working together.

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CARDIOVASCULAR DISEASE
Risk Factors for Cardiovascular Disease
1. Risk factors that cannot be changed (Non-modifiable)
• Heredity • Age • Gender

2. Risk factors that can be changed (modifiable)


• Cigarette Smoking • Hypertension • Stress
• Obesity • Diabetes Mellitus • Lack of Exercise
• Elevated cholesterol and triglyceride level

SL.ppt/TR/FC 30 56
CARDIOVASCULAR DISEASE
Myocardial Infarction – it occurs when the oxygen supply to the heart
muscle (myocardium) is cut–off for a prolonged period of time. This cut-
off results from a reduced blood supply due to severe narrowing or
complete blockage of the diseased artery. The result is death (infarction)
of the affected part of the heart.

Warning Signals
Chest discomfort characterized by:
• Uncomfortable pressure, squeezing, fullness or tightness, aching,
crushing, constricting, oppressive or heavy.
• Sweating • Nausea • Shortness of breath

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CARDIOVASCULAR DISEASE
Firs Aid Management

• Recognize the signals of heart attack and take action.


• Have patient stop what he or she is doing and have him/her sit or lie
down in a comfortable position. Do not let the patient move around.
• Have someone call the physician or ambulance for help
• If patient is under medical care, assist him/her in taking his/her
prescribe medicine/s.

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Medical Conditions for
Applying Basic Life Support
1. When a patient with the following
Respiratory conditions are in distress:
Bronchitis, Pneumonia, Chronic Obstructive
Pulmonary Disease (COPD) ---- perform
Rescue Breathing / CPR

2. Cardiac arrest ---- perform CPR

SL.ppt/TR/FC 29 59
Con’t of Conditions for applying BLS
3.Anatomical Obstruction – when the tongue
drops back and obstructs the throat. Others
causes are acute asthma, croup, diphtheria,
swelling and whooping cough. --- perform
Rescue Breathing / CPR

4.Mechanical Obstruction – when foreign


objects lodge in the pharynx or airways;
fluids accumulate in the back of the throat.

SL.ppt/TR/FC 31 60
Con’t of Conditions for applying BLS
Con’t. of Mechanical Obstruction
* If conscious adult /child, perform
Abdominal Thrust or Rescue Breathing
* If unconscious adult/child, perform chest
thrust (CPR)
* If conscious infant, perform chest thrust
and back slap
* If unconscious infant, perform, chest thrust
(CPR)

SL.ppt/TR/FC 32 61
Con’t of Conditions for applying BLS
5. Other causes:
* Electrocution, electric shock or lightning
strikes
* External strangulation
* Drowning
* Poisoning
* Suffocation
* Chest compression by other physical
forces

SL.ppt/TR/FC 33 62
Con’t of Conditions in applying BLS

Other causes may be treated by doing either


rescue breathing, cardio-pulmonary
Resuscitation, abdominal thrust, or chest thrust
and back slap depending on the situation.

SL.ppt/TR/FC 34 63
PRIMARY SURVEY
• Focus: Basic CPR and Defibrillation
1. Check for responsiveness
2. Activate Emergency Response System
3. Call for defibrillator

C= Circulation: Give chest compressions 30:2


A= Airway: Open airway
B= Breathing: Check breathing
Provide 2 positive pressure ventilations
D= Defibrillation: Assess for and Shock VF &
Pulseless VT

SL.ppt/TR/FC 34 64
DID WE MEET OUR OBJECTIVES?
WERE YOU ABLE TO:

1. Explain the concept of the session.


2. Identify the three kinds of Life Support.
3. Identify the five links in the Chain of
Survival for Adult and Pediatric patients
4. Identify the anatomical positions, directions,
locations and regions of the human body.

SL.ppt/TR/FC 35 65
DID WE MEET OUR OBJECTIVES?
WERE YOU ABLE TO:
5. Discuss the anatomy and physiology of the
respiratory, circulatory, and nervous systems.
6. Discuss the Medical conditions for applying
Basic Life Support

SL.ppt/TR/FC 36 66
Session 3
BLS for HCP
Cardiopulmonary
Resuscitation

SL.ppt/TR/FC 20 67
OBJECTIVES:

At the end of this session participants should be able


to:
a. Define cardiopulmonary resuscitation
b. Perform correct cardiopulmonary
resuscitation techniques to an adult, child
and infant who are in cardiac arrest
c. Discuss other alternative forms of CPR
d. Enumerate the criteria for when to start, not
to start and when to stop CPR

SL.ppt/TR/FC 2 68
CARDIOPULMONARY
RESUSCITATION (CPR)
• is series of assessments and interventions
using techniques and maneuvers made to
bring victims of cardiac and respiratory
arrest back to life.
Cardiopulmonary Resuscitation
WHEN NOT TO START CPR

All victims of cardiac arrest should receive CPR unless:


1. Patient has a valid DNAR (Do Not Attempt
Resuscitation) order.
2. Patient has signs of irreversible death (Rigor Mortis,
Decapitation, Dependent Lividity).
3. No physiological benefit can be expected because
the vital functions have deteriorated as in septic or
cardiogenic shock.

71
WHEN NOT TO START CPR

All victims of cardiac arrest should receive CPR unless:

4. Confirmed gestation of < 23 weeks or birth weight <


400 grams, anencephaly.

5. Attempts to perform CPR would place the rescuer at


risk of physical injury.

72
When to Stop CPR?
S - SPONTANEOUS signs of circulation are
restored
T -TURNED over to medical services or properly
trained and authorized personnel
O - OPERATOR is already exhausted and cannot
continue CPR
P - PHYSICIAN assumes responsibility (declares
death, takes over, etc.)
S – SCENE becomes unsafe (such as traffic,
impending or ongoing violence—gun fires, etc)
S – SIGNED waiver to stop CPR
ADULT BLS SEQUENCE
• Immediate recognition and
Activation of the
Emergency Response
Sytem (EMS)
– Establish scene safety first
– Check for a response by
tapping the victim on the
shoulder and shouting at
the victim
• Simultaneously look for no
breathing or gasping
– Activate EMS
CHECK FOR RESPONSIVENESS
• ADULT and
CHILD BLS
– Tap the shoulders
to check for
responsiveness
• INFANT BLS
– Tap the sole of the
feet to check for
responsiveness
ADULT BLS SEQUENCE
• Pulse Check
– Check pulse no
more than 10
seconds
– If there is no
pulse start CPR
PULSE CHECK
• Check for no longer than
10 seconds (7 seconds
better)
• Adult BLS
– Check for Carotid
Pulse
• Pedia BLS
– Child BLS
• Check for Carotid
pulse
– Infant BLS
• Check for Brachial
Pulse
The C-A-Bs…
• Core concept: Oxygen to the Brain!
• In order: Compression-Airway-Breathing
• These build on each other.
• “You cannot breathe for a patient or
assess breathing without first opening the
airway.”
• ALWAYS FOLLOW YOUR CAB’s!!!

78
Reason: AHA 2010 Guidelines
• Early CPR improves the likelihood of
survival.
• Chest Compressions are the foundations
of CPR.
• Compressions create blood flow by
increasing intra-thoracic pressure and
directly compress the heart; generate
blood flow and oxygen delivery to the
myocardium and brain.
Basic Life Support ebec 79
2009
CHANGES OF BLS 2010 FROM BLS 2005
• “Look, Listen, and Feel” removed from the
BLS algorithm
• Sequence change to chest compressions
before rescue breaths
– CAB
• C : Circulation
• A : Airway
• B : Breathing
– rather than ABC

Basic Life Support ebec 80


2009
CPR: C- CIRCULATION

• CIRCULATION represents a heart that is


actively pumping blood, most often
recognized by the presence of a pulse in the
neck
• Assume there is no CIRCULATION if the
following exist: Unresponsive, Not breathing,
Not moving and Poor skin color

“SIGNS OF CIRCULATION”

Basic Life Support ebec 81


2009
ADULT BLS SEQUENCE
• Early CPR
– Chest Compressions
• Push Hard Push Fast
• Rate: at least 100/min
– should take 15-18 sec
• Depth: at least 2 inches
or 5cm for Adults
• Depth: at least 1/3 of the
AP diameter of the chest
– Infants: 1 ½ inches(4cm)
– Chilldren: 2 inches(5cm)
• Allow complete chest
recoil
• Minimize interruptions

Basic Life Support ebec 82


2009
CHEST COMPRESSIONS
• Kneel facing the victim’s chest
• Place the heel of one hand on
the sternum in the center of the
chest between the nipples and
then place the heel of the
second hand on top of the first
so that the hands are
overlapped and parallel.

83
CHEST COMPRESSIONS
• Position shoulders over
hands with elbows
locked and arms
straight
• Compress down and
release pressure
smoothly, keeping hand
contact with chest at all
times

84
ADULT BLS SEQUENCE
• Early CPR
– Rescue Breaths
• Deliver rescue
breath over 1 second
• Allow visible chest
rise
• Compression:Ventila
tion ratio of 30:2
• 5 cycles or 2 minutes

85
CPR: A- Open AIRWAY

• This must be done to


ensure an open passage for
spontaneous breathing OR
mouth to mouth during CPR
• Head-Tilt/Chin-Lift
Tilt the head back with your
hand and lift up on the chin
• Jaw Thrust Maneuver if
considering spinal injury

86
CPR: A- Open AIRWAY

• Jaw-Thrust Maneuver
is strictly a Healthcare
Provider technique
and not for Lay
Rescuers (if
suspected with
cervical trauma)

87
BREATHING
• Maintain airway
• Pinch nose shut
• Open your mouth wide, take a
normal breath, and make a
tight seal around outside of
victim’s mouth
• Give 2 full breaths (1 sec/
breath)
• Observe chest rise

88
CPR
• Continue CPR until
– AED arrives and is ready for use
– EMS providers take over the care of the
victim
• Cycles of 30 compressions:2 ventilations
should be continued until an advanced airway
is placed
– Continuous compressions
– Ventilation rate of 1 breath every 6 to 8
seconds
89
1 and 2 Rescuer Adult CPR
1. Establish scene safety.

2. Introduce self to establish authority.

3. Determine unresponsiveness (movement &


breathing)

4. IF unresponsive and not breathing or gasping,


call for HELP! Activate EMS and get the AED.

90
1 and 2 Rescuer Adult CPR
5. Pulse check within 10 seconds (for HCP).

6. Perform 30 Compressions on the chest

7. Open Airway- Head/Tilt chin lift and perform


2 Rescue Breaths

8. Do this for 5 cycles or approx. 2 minutes.


Rescuer may switch roles.

91
1 and 2 Rescuer Adult CPR

9. Do this until AED/Defibrillator arrives, ALS


provider takes over, or victim starts to move.

10. If patient becomes conscious, place patient in


recovery position

92
Pediatric CPR
Child CPR
 Lower half of the sternum, between the
nipples.
 Depth: 1/3 of the AP Diameter of the
chest
 2 inches (5 cm) depth
 One hand only/ two hands
 30:2 for single rescuer, 15:2 for 2-man
rescuer (optional for HCP).
93
Pediatric CPR
Infant CPR
 Just below the nipple line, lower half of
sternum
 Depth: 1/3 of the AP Diameter of the
chest
 1 1/2 inches (4 cm) depth
 Two fingers, flexing at the wrist (lone rescuer)
 2-thumbs hand encircling technique (two
rescuers)

94
1 – Rescuer Pediatric CPR
1. Survey the scene.

2. Introduce Self

3. Check for responsiveness

4. IF unresponsive and not breathing or gasping,


call for HELP! Activate EMS and get the AED.
If you are a lone rescuer do 5 cycles of CPR
before calling for help
SL.ppt/TR/FC 20 95
1 – Rescuer Pediatric CPR
5. Perform 30 Compressions on the chest

6. Open Airway -Head/Tilt chin lift and perform 2


Rescue Breaths

7. Do this for 5 cycles or approx. 2 minutes.

8. Do this until AED/Defibrillator arrives, ALS


provider takes over, or victim starts to move.

SL.ppt/TR/FC 20 96
2- Rescuer Pediatric CPR
1. Survey the scene.

2. Introduce Self

3. Check for responsiveness

4. IF unresponsive and not breathing or gasping,


call for HELP! Activate EMS and get the AED.

SL.ppt/TR/FC 20 97
2- Rescuer Pediatric CPR
5. 1st Rescuer performs 15 chest Compressions (
for infant victims do two thumbs CPR)

6. 2nd Rescuer opens the Airway- Head/Tilt chin


lift and delivers 2 Rescue Breaths

7. Do CPR 15:2 for 10 cycles or approx. 2 mins.

8. Reassess for less than 10 secs. Rescuers may


switch roles
SL.ppt/TR/FC 20 98
2- Rescuer Pediatric CPR

9. Do this until AED/Defibrillator arrives, ALS


provider takes over, or victim starts to move.

10. If patient becomes conscious, place patient in


recovery position

SL.ppt/TR/FC 20 99
Alternative CPR
Compression-only CPR:

 Outcome is better than outcome of NO CPR

 Lay rescuers should do compression-only if


they are unwilling or unable to provide rescue
breaths
Table of Comparison on Cardiopulmonary Resuscitation
ADULT CHILD INFANT
Compression Lower half of sternum, between the nipples Just below the nipple
Landmark line (lower half of
sternum)
Location for Pulse Carotid Pulse Carotid Pulse or Brachial Pulse or
Check (HCP only) Femoral Pulse Femoral Pulse
Compression Depth At least 2 inches At least 1/3 of the AP Diameter of the chest
(5 cm) About 2 in (5 cm) About 1 1/2 in (4 cm)
Compression method Heel of one hand Heel of one hand Lone Rescuer: 2
(Push hard and fast, with hand of the with hand of the finger technique
Allow Complete recoil) other on top other on top or one 2 HCP rescuers: 2-
hand technique thumbs hand
encircling technique
Compression rate At least100 Compressions per minute
Counting for 1-29, 1 up to 5 cycles
Standardization (30 compressions within 18 seconds)
Purpose 1-14, 1 up to 10 cycles for 2-rescuer Pedia
CPR
(15 compressions within 9 seconds)
Compression- 1 or 2 - Rescuer 1-rescuer (30:2)
Ventilation Ratio (30:2) 2-rescuer (15:2)
DONT's in External Chest Compression
1. Jerker

2. Massager

3. Bender

4. Rocker

5. Bouncer

6. Double Crosser
Recovery Position in CPR
• Adult and Child
Recovery Position in CPR
• Adult and Child
Recovery Position in CPR
• Adult and Child
Recovery Position in CPR
• Adult and Child
QUESTIONS?

WERE WE ABLE TO:

a. Define cardiopulmonary resuscitation


b. Perform correct cardiopulmonary
resuscitation techniques to an adult, child
and infant who are in cardiac arrest
c. Discuss other alternative forms of CPR
d. Enumerate the criteria for when to start, not
to start and when to stop CPR

SL.ppt/TR/FC 2 107
BLSSession
for HCP4
Respiratory Arrest and
Rescue Breathing
( not included for Lay Rescuers)
SL.ppt/TR/FC 20 108
OBJECTIVES:
At the end of this session, participants shall be able to
correctly:

1. Explain the concept of rescue breathing;


2. Describe what is Respiratory Arrest and its causes;
3. Discuss the significance of Rescue Breathing in
respiratory arrest;
4. Identify the different ways in ventilation; and
5. Demonstrate Rescue Breathing techniques for an
adult, child, & infant.

SL.ppt/TR/FC 37 109
Is the condition in which breathing stops or is inadequate.

1. Obstruction
1.1 Anatomical
1.2 Mechanical
2. Diseases
2.1 Bronchitis
2.2 Pneumonia
2.3 COPD

110
3. Other causes
3.1 Electrocution
3.2 Circulatory Collapse
3.3 Strangulation
3.4 Chest Compression ( by other physical force )
3.5 Drowning
3.6 Poisoning
3.7 Suffocation

111
● Is a technique of breathing air into
a person’s lungs to supply him or
her with the oxygen needed to
survive.
●Given to victims who are not
breathing or inadequate but still
have pulse.
● Crucial tool to revive the individual
or keep him or her until the help
comes.

112
1. Mouth-to-Mouth
113
2. Mouth-to-Nose
114
3. Mouth-to-Mouth and Nose
115
4. Mouth-to-Stoma
116
5. Mouth-to-Face Shield
117
6. Mouth-to-Mask
118
7. Bag Valve Mask Device
119
SPECIAL CONSIDERATIONS
● Rescuer to avoid pressing soft
tissue under the chin this might
obstruct the airway
● Rescuer not to use the thumb to lift the
chin
● Rescuer not to close the victim’s mouth
completely (unless mouth to nose is
the technique)

120
SPECIAL CONSIDERATIONS
● Each rescue breath should give
enough air to make the chest rise and
be given at 1 second;
● Rescuer should avoid delivering more
breaths (more than the number
recommended) or breaths that are too
large or too forceful.

121
SPECIAL CONSIDERATIONS
● Rescuers should take a normal breath
(not a deep breath) mouth to mouth or
mouth-to-barrier device rescue breaths.

122
Table of Comparison on Rescue Breathing
ADULT CHILD INFANT

Opening of airway Head Tilt-Chin Lift


(Head-Tilt_ Chin-Lift (HCP: If suspected spine injury perform Jaw thrust maneuver)
Maneuver)
Mouth-to-mouth or mouth-to-nose Mouth-to-mouth and
Method
nose
Normal breath enough to make the chest rise
Amount of Breath

1 breath every 5 – 6
1 breath every 3 - 5 seconds then reassess
seconds then
Rate every 2 minutes
reassess every 2
minutes

Breathe 1001,1002,
Counting for
1003, 1004, 1005,
Standardization Breathe 1001,1002, 1003, breathe
breathe
Purposes

123
Session 5
BLS for HCP
Automated External
Defibrillator (AED)

124
OBJECTIVES:
After completing this session, participants will be able to:

1. Define AED
2. Explain the indications and importance of early
defibrillation.
3. Enumerate the 4 universal steps of an AED operation.
4. Explain the special conditions that affect the use of an AED

125
Basic Life Support Visual Aids
DOH-HEMS Automated External Defibrillator (AED)

SKILL OBJECTIVE:
After completing this session, participants
will be able to -

• Demonstrate how to properly use AED to an


adult, child & infant who are in cardiac arrest.
Basic Life Support Visual Aids
DOH-HEMS Automated External Defibrillator (AED)

Definition

AEDs are sophisticated, computerized devices that can


analyze heart rhythms and generate high voltage
electric shocks.
Basic Life Support Visual Aids
DOH-HEMS Automated External Defibrillator (AED)

Indications and Importance


Early defibrillation is critical for victims of
sudden cardiac arrest because:
• The most frequent rhythm in sudden
cardiac arrest is VF
• The most effective treatment for VF is
defibrillation
• Defibrillation is most likely to be
successful if it occurs within minutes
of collapse (cardiac arrest)
• Defibrillation may be ineffective if it is
delayed
• VF deteriorates to asystole if not
treated
Basic Life Support Visual Aids
DOH-HEMS Automated External Defibrillator (AED)

Ventricular Fibrillation (VF)


• VF is a common and treatable initial rhythm in
adults with witnessed cardiac
• Survival rates are highest when immediate
bystander CPR is provided and defibrillation
occurs within 3 to 5 minutes of collapse
• Rapid defibrillation is the treatment of choice
• Rhythm causing ‘all’ sudden cardiac arrest
• Useless quivering of the heart  no blood flow
• Myocardium is depleted of oxygen & metabolic
substrates
Basic Life Support Visual Aids
DOH-HEMS Automated External Defibrillator (AED)
Basic Life Support Visual Aids
DOH-HEMS Automated External Defibrillator (AED)

Defibrillation

• Shock success
– Termination of VF for at least 5 seconds
following the shock

• VF frequently recurs after successful


shocks & these recurrence should not be
equated to shock failure
Basic Life Support Visual Aids
DOH-HEMS Automated External Defibrillator (AED)

Causes of VF and
Cardiac Arrest
Hypoxia
– Near drowning
– Burst lung
– Decompression illness
– Rebreather malfunction
– Choking
– Carbon monoxide poisoning
Bleeding
Heart attack
Drug overdose
Basic Life Support Visual Aids
DOH-HEMS Automated External Defibrillator (AED)

Automated External Defibrillator


(AED)
– Controlled electrical shock
– May restore an organized
rhythm
– Enables heart to contract &
pump blood
Basic Life Support Visual Aids
DOH-HEMS Automated External Defibrillator (AED)

Evidence
100

For every minute


Survival Rate

80
defibrillation is delayed
the victim’s survival rate
(%)

60
decreases by 10%

40

20

0
5 10 15 20 25 30
Time to Defibrillation
(minutes)
Basic Life Support Visual Aids
DOH-HEMS Automated External Defibrillator (AED)

Several factors that can affect AED


analysis
• Patient movement (eg. agonal gasp)
• Repositioning the patient

Use AED only when victims have the


following 3 clinical findings
• No response
• No breathing
• No Pulse
Note: Defibrillation is also indicated for pulseless ventricular tachycardia (VT)
Basic Life Support Visual Aids
DOH-HEMS Automated External Defibrillator (AED)

Special Conditions that Affect


the Use of AED

• The victim is1 month old or less.


• The victims has a hairy chest.
• The victim is lying in water, immersed in water,
or water is covering the victim’s chest.
• The victim has implanted defibrillator, or
pacemaker.
• The victim has a transdermal medication patch
or other object on the surface of the skin where
the AED electrode pads are placed.
Basic Life Support Visual Aids
DOH-HEMS Automated External Defibrillator (AED)

Different Types of AED


1. AED Trainer
Not capable of delivering a shock
Do not allow to be confused with real units

2. Semi-automated Defibrillator
Requires the user to press the button for analysis
and shock

3. Fully Automated Defibrillator


No intervention required for analysis and shock
They are programmed to run self-test and they will
indicate when maintenance is needed
Basic Life Support Visual Aids
DOH-HEMS Automated External Defibrillator (AED)

How Does Defibrillation Work?


1. A brief high voltage electrical shock
2. Through the heart between pads on the chest
3. Shock briefly stops electrical heart activity
4. May restart beating with a normal rhythm
5. But not everyone can be saved, even with
defibrillation
Basic Life Support Visual Aids
DOH-HEMS Automated External Defibrillator (AED)

Parts of an AED
Example: AED Trainer
Pads connector port
On button

Analyze
button

Shock
button
Pads
Defibrillator
Basic Life Support Visual Aids
DOH-HEMS Automated External Defibrillator (AED)

Automated External Defibrillator (AED)


• Placed in areas of public access
– railway stations
– Airports
– Shopping centers
• Stored in:
– Secure display units
– Accessible to all trained rescuers
– Clearly marked
• Should always be stored ready to use with a fully
charged battery
• Razors to shave the casualty’s chest should be
stored with the defibrillator, along with gloves in
various sizes
Basic Life Support Visual Aids
DOH-HEMS Automated External Defibrillator (AED)

IF YOU ARE NOT SURE ABOUT THE


WAVEFORM OF YOUR BIPHASIC
DEFIBRILLATOR

200 JOULES
Basic Life Support Visual Aids
DOH-HEMS Automated External Defibrillator (AED)

PAAS
Basic Life Support Visual Aids
DOH-HEMS Automated External Defibrillator (AED)

AED Procedures
BLS until AED available
Diagnose cardiac arrest
– Unresponsive
– Not breathing
normally
Go for or send someone
for AED
30 compressions
• 2 rescue breaths
• Continue 30:2
• CC + RB = “CPR”
Basic Life Support Visual Aids
DOH-HEMS Automated External Defibrillator (AED)

Attach AED

Power on

Follow voice prompts

Expose the chest


Basic Life Support Visual Aids
DOH-HEMS Automated External Defibrillator (AED)

Attach AED (cont’d)

Dry skin/shave if
necessary
Basic Life Support Visual Aids
DOH-HEMS Automated External Defibrillator (AED)

Attach AED pads


Adult pads vs Child pads
Basic Life Support Visual Aids
DOH-HEMS Automated External Defibrillator (AED)

Attach AED (cont’d)

Attach pads

Keep following voice


prompts

Clear the victim and press


analyze button
Basic Life Support Visual Aids
DOH-HEMS Automated External Defibrillator (AED)

AED Safety
• With every analysis and shock
NO ONE TOUCHES THE
PATIENT!
• Verbal warning to bystanders:
– “I am shocking on three,
everybody clear 1, 2, 3”
– Physical and hand gestures
• Only then press to SHOCK!
Basic Life Support – CPR Visual Aids
DOH-HEMS Introduction to BLS - CPR
Basic Life Support Visual Aids
DOH-HEMS
Adult BLS Algorhythm

1 Adult BLS Algorithm


Unresponsive
No Breathing or no normal breathing
(ie, only gasping)
2

Activate Emergency Response System


Get AED/Defribillator
Or send second rescuer (if available) to do this

3 3A

Check pulse: Definite • Give 1 breath every


Pulse 5 to 6 seconds
DEFINITE pulse
Within 10 seconds • Recheck pulse every
4 2 minutes

Begin cycles of 30 COMPRESSIONS


and 2 BREATHS
Basic Life Support Visual Aids
DOH-HEMS Adult BLS Algorhythm

5
AED/defibrillator ARRIVES

Check Rhythm
Shockable rhythm?
Not Shockable

Shockable

7 8

Give 1 shock Resume CPR immediately


Resume CPR immediately for 5 cycles
for 5 cycles Check rhythm every
5 cycles; continue until ALS
providers take over or
victim starts to move

Note: The boxes bordered with dashed lines are performed


by healthcare providers and not by lay rescuers

Adult BLS Algorithm


Basic Life Support Visual Aids
DOH-HEMS
Pediatric BLS Algorhythm

1 Unresponsive Pediatric BLS Algorithm


Not breathing or only gasping
Send someone to activate emergency
response system, get AED/defibrillator
2
Lone Rescuer: For SUDDEN COLLAPSE,
activate emergency response system,
get AED/ defibrillator
3 3A
Definite
Check pulse: • Give 1 breath every 3
Pulse
seconds
DEFINITE pulse • Add compressions if pulse
Within 10 seconds remains <60/min with poor
perfusion despite adequate
oxygenation and ventilation
• Recheck pulse every 2
minutes
4

One Rescuer: Begin cycles of 30 COMPRESSIONS and 2 BREATHS


Two Rescuers: Begin cycles of 15 COMPRESSIONS and 2 BREATHS
Basic Life Support Visual Aids
DOH-HEMS Pediatric BLS Algorhythm

After about 2 minutes, activate emergency response system and get


AED/ defibrillator (if not already done).
Use AED as soon as available.
6

Check Rhythm
Shockable rhythm?
Not Shockable

Shockable
7 8

Give 1 shock Resume CPR immediately


Resume CPR immediately for 5 cycles
for 5 cycles Check rhythm every
5 cycles; continue until ALS
providers take over or
victim starts to move
Note: The boxes bordered with dashed lines are performed
by healthcare providers and not by lay rescuers
Pediatric BLS Algorithm
Basic Life Support – CPR Visual Aids
DOH-HEMS Introduction to BLS - CPR

AED Video
Session 6
Foreign Body Airway
Obstruction Management

155
OBJECTIVES:
At the end of this session, participants shall be
able to effectively:

1. Explain the concept of FBAO


management.
2. Discuss the causes, types and
classification of obstruction
3. Discuss theory and precaution of
abdominal thrust

SL.ppt/TR/FC 45 156
4. Demonstrate proper application of abdominal
thrust to conscious and unconscious adult and
child
5. Demonstrate back slap and chest thrust to a
conscious and unconscious infant
6. Demonstrate self administration of abdominal
thrust.
7. Demonstrate the proper technique of abdominal
thrust under special circumstances as in pregnant
women, and obese victim.

SL.ppt/TR/FC 20 157
- is a condition when solid material like chunked foods,
coins, vomitus, small toys etc. are blocking the airway.

SL.ppt/TR/FC 20 158
1. IMPROPER CHEWING OF LARGE PIECES OF FOOD
2. EXCESSIVE ALCOHOL INTAKE –
a. relaxation of tongue back into the throat
b. Aspirated vomitus (stomach content)
3. PRESENCE OF LOOSE UPPER AND LOWER DENTURES
4. FOR CHILDREN WHO ARE RUNNING WHILE EATING
5. FOR SMALLER CHILDREN OF HAND-TO-MOUTH STAGE LEFT UNATTENDED.

SL.ppt/TR/FC 46 159
1. ANATOMICAL OBSTRUCTION

2. MECHANICAL OBSTRUCTION

SL.ppt/TR/FC 47 160
1. ANATOMICAL OBSTRUCTION
It happens when the tongue drops back and obstructs the throat. Other
causes are acute asthma, croup, diphtheria, swelling, and cough
(whooping).

SL.ppt/TR/FC 47 161
2. MECHANICAL OBSTRUCTION
When foreign objects lodge in the pharynx
or airways; fluids accumulate in the back of the
throat.

SL.ppt/TR/FC 48 162
1. MILD OBSTRUCTION

2. SEVERE OBSTRUCTION

SL.ppt/TR/FC 20 163
1. MILD OBSTRUCTION

A. Signs:

1. Good air exchange


2. Responsive and can cough forcefully
3. May wheeze between coughs.
4. Has increased respiratory difficulty and possibly cyanosis.

SL.ppt/TR/FC 20 164
B. Rescuer Actions:
As long as good air exchange continues,
1. Encourage the victim to continue spontaneous coughing and
breathing efforts.
2. Do not interfere with the victim’s own attempts to expel the foreign
body, but stay with the victim and monitor his or her condition.
3. If patient becomes unconscious/unresponsive, activate the
emergency response system.

SL.ppt/TR/FC 20 165
2. SEVERE OBSTRUCTION

A. Signs:

1. Poor or no air exchange,


2. Weak or ineffective cough or no cough at all,
3. High-pitched noise while inhaling or no noise at all,
4. Increased respiratory difficulty,
5. Cyanotic (turning blue)

SL.ppt/TR/FC 20 166
cont.
6. Unable to speak
7. Clutching the neck with the thumb and fingers making the
universal sign of choking.
8. Movement of air is absent.

B. Rescuer Actions:
Ask the victim if he or she is choking. If the victim nods and
cannot talk, severe airway obstruction is present and you must
perform abdominal/chest thrust and once becomes
unconscious/unresponsive activate the emergency response
system.

SL.ppt/TR/FC 20 167
-is a sign
wherein the
victim is
clutching his/her
neck with one or
both hands and
gasping for
breath.

168
Abdominal thrusts is an emergency
procedure for removing a foreign
object lodged in the airway that is
preventing a person from
breathing.

REMEMBER :
A.T. should not be used in infants
under 1 year of age due to risk of
causing injury.

169
3
2
1

air

Site
(compression)

170
SL.ppt/TR/FC 20
Foundation Facts:
Complications from Abdominal Thrusts

1. Incorrect application of the Abdominal Thrust can


damage the chest, ribs and internal organs.
2. May also vomit after being treated with the Abdominal Thrust.
3. They should be examined by a Physician to rule out any
life-threatening complications.

SL.ppt/TR/FC 20 171
• Back slaps / Chest thrust to a conscious infant

SL.ppt/TR/FC 20 172
OBVIOUSLY PREGNANT AND VERY
OBESE PEOPLE

 The main difference in performing the Abdominal


Thrust on this group of people is in the placement of
the fists.
 Instead of using abdominal thrusts, chest thrusts
are used.
 The fists are placed against the middle of the
breastbone and do the chest thrust
 If the victim is unconscious, the chest thrusts are
similar to those used in CPR.

SL.ppt/TR/FC 20 173
• Caution: Pregnant and Obese Victims
If the pregnant or obese victim becomes
unconscious, call for HELP and perform CPR.

SL.ppt/TR/FC 20 174
OBESE VICTIM

OBESE VICTIM

SL.ppt/TR/FC 20 175
FBAO Management –
Adult / Child / Infant

1. Determine scene safety.


2. Introduce yourself patient, guardian and or
bystander.
3. Determine level of breathing difficulty by checking:
a. Infant- ineffective coughs, weak or absence of
cry. if so, tell parents/guardian that you are
there to help.
b. Child/Adult- by asking if the victim is choking.
If so, tell the victim that you are there to help.
4. Properly position the patient.
a. Infant- support the infant on
rescuer’s knee or lap
b. Child/Adult - Assume straddle
position behind.
5. Locate proper site:
a. Infant- give 5 back slaps and 5
chest thrust using 2 fingers techniques.
b. Child/Adult- for abdominal thrust, properly
position balled fist on the patient
Properly perform abdominal thrust.

SL.ppt/TR/FC 20 177
Con’t
6. Carefully lay down unconscious patient.
7. Call for help to activate Medical Assistance (for
pediatrics and adults) and perform CPR.
8. Check oral cavity for presence of obstruction. If
foreign body is visible perform finger sweep, if not
visible properly administer first RB.
9. If air bounce back, re-position patient’s head and
properly administer second RB.
10. After 2 minutes, if not yet done, activate
EMS.
11. If still unconscious, perform CPR and
apply AED if available.
12. If patient becomes conscious, properly
place patient in recovery position.
Basic Life Support – CPR Visual Aids
DOH-HEMS Introduction to BLS - CPR

FBAO Video
DID WE MEET OUR OBJECTIVES?
WERE WE ABLE TO :

• Understand the concept of FBAO management.


- Definition of FBAO

• Discuss the:
- causes
- types
- classification of obstruction

SL.ppt/TR/FC 45 181
DID WE MEET OUR OBJECTIVES ?
WERE WE ABLE TO :

• Discuss theory and precaution of abdominal thrust


• Demonstrate proper application of abdominal thrust to
an adult and child who is :
- conscious
- unconscious

SL.ppt/TR/FC 20 182
DID WE MEET OUR OBJECTIVES ?
WERE WE ABLE TO :

• Demonstrate back slap and chest thrust to a


- conscious
- unconscious infant
• Demonstrate self administration of abdominal thrust.
• Demonstrate the proper technique of abdominal thrust
under special circumstances as in
- pregnant women
- obese victim.

SL.ppt/TR/FC 20 183