BLS PROVIDER MANUAL
Basic Life Support Table of Contents Basic Life Support Table of Contents .......................................................................................................... 1 Table of Figures ........................................................................................................................................... 2 General Concepts of Basic Life Support ...................................................................................................... 3 Initiating the Chain of Survival ................................................................................................................ 3 2010 BLS Guidelines Changes ................................................................................................................. 4 BLS for Adults .............................................................................................................................................. 6 One Rescuer Adult BLS ............................................................................................................................ 6 One Rescuer CPR ..................................................................................................................................... 7 Two Rescuer Adult BLS/CPR .................................................................................................................... 8 Adult Mouth-to-Mask Ventilation .......................................................................................................... 8 Adult Bag-Mask Ventilation in 2-Rescuer CPR ........................................................................................ 8 Use of the Automated External Defibrillator (AED) .................................................................................... 9 AED Use for Infants and Children ............................................................................................................. 10 BLS for Children (Age 1 to Puberty) .......................................................................................................... 10 One Rescuer BLS for Children ............................................................................................................... 11 Two Rescuer BLS for Children ............................................................................................................... 12 Child Ventilation.................................................................................................................................... 12 BLS for Infants (0 to 12 months old) ......................................................................................................... 12 One Rescuer BLS for Infants .................................................................................................................. 13 Two Rescuer BLS for Infants ................................................................................................................. 14 CPR with an Advanced Airway .................................................................................................................. 14 Mouth-to-Mouth Rescue Breathing ......................................................................................................... 15 Adult and Older Children Mouth-to-Mouth ......................................................................................... 15 Infant Mouth-to-Mouth or Mouth-to-Nose ......................................................................................... 16 Rescue Breathing .................................................................................................................................. 16 Relief of Choking ....................................................................................................................................... 17 Choking in an Adult or Child Older than One Year ............................................................................... 17 Choking in Infants (Less than one year old) .......................................................................................... 19
Table of Figures Figure 1: Adult Chain of Survival ................................................................................................................. 3 Figure 2: Pediatric Chain of Survival ........................................................................................................... 4 Figure 3: 2010 BLS Changes ........................................................................................................................ 4 Figure 4: Adult BLS ...................................................................................................................................... 6 Figure 5: One Rescuer CPR .......................................................................................................................... 7 Figure 6: Using an AED for Adults ............................................................................................................... 9 Figure 7: Differences in BLS for Adults and Children ................................................................................ 10 Figure 8: One Rescuer BLS for Children .................................................................................................... 11 Figure 9: One Rescuer Infant BLS .............................................................................................................. 13 Figure 10: Compression to Breath Ratios with/without Advanced Airway .............................................. 14 Figure 11: Adult & Older Child Mouth to Mouth ...................................................................................... 15 Figure 12: Rescue Breathing ..................................................................................................................... 16 Figure 13: Adult and Child Airway Obstruction ........................................................................................ 17 Figure 14: Abdominal Thrusts for Adult/Child Choking ............................................................................ 18 Figure 15: Infant Airway Obstruction ....................................................................................................... 19 Figure 16: Back Blows/Chest Thrusts for Choking Infant.......................................................................... 20
General Concepts of Basic Life Support The American Heart Association (AHA) Basic Life Support (BLS) course has changed dramatically over the years to make it more accessible to the general public and more effective for the victim of cardiac arrest. Cardiac arrest is the leading cause of death in the world. Providers of BLS can intervene early and possibly prevent a death associated with sudden cardiac arrest. The elements of BLS are:
Initiating the chain of survival as soon as a possible problem is identified;
Initiating early and high quality chest compressions for any victim;
Providing early defibrillation with an Automated External Defibrillator (AED) when one is available;
Initiating rescue breathing when respiration are i nadequate;
Performing BLS as a team; and
Relieving a choking episode.
Initiating the Chain of Survival Research shows that BLS can increase the rate of survival for certain victims of cardiac arrest. It is critical that the Adult Chain of Survival is initiated quickly and performed at a high level of quality. Activate the Emergency Response System
Early and High Quality CPR
Rapid Defibrillation
Effective Advanced Life Support
Post Cardiac Arrest Care
Figure 1: Adult Chain of Survival
Typically, pediatric victims begin the collapse process after suffering dehydration or respiratory problems. This population will rarely have a primary cardiac arrest. If respiratory events and dehydration can be prevented, cardiac arrest can often be avoided. Therefore, it is critical to prevent the need for resuscitation in infants and children. Prevent the need for resuscitation
Perform High Quality CPR
Call 911 to activate the emergency system
Provide Advanced Life Support
Provide Post Cardiac Arrest Care
Figure 2: Pediatric Chain of Survival
2010 BLS Guidelines Changes In 2010, the American Heart Association (AHA) made some important changes to the BLS Guidelines. These revisions are: Guideline Steps in the process Look, listen and feel for breathing CPR Cricoid Pressure Pulse Check
Old Guideline ABC (airway, breathing, compressions) "Look, listen and feel" for breathing with two rescue breaths
Use of AED in Infants
Not recommended
Slower rate, less depth Ofte used during difficult intubation For at least 15 seconds
Figure 3: 2010 BLS Changes
2010 Guideline CAB (compressions, airway, breathing) Begin CPR if the victim is unresponsive, pulseless, and not breathing or if the breathing is gasping High Quality CPR (see definition below) No longer recommended during the advanced care of the victim 10 seconds or less and start CPR if not certain that pulse is present Use an AED as soon as it is available for all ages
Research shows that beginning compressions early increases the chance of survival so the sequence has been changed from “ABC” to “CAB” (Chest Compressions, Airway, Breathing).
The importance of high-quality CPR is stressed. High quality CPR includes: o
Perform compressions at a rate of AT LEAST 100 per minute regardless of the age of the victim;
o
Increase the compression depth to AT LEAST 2 inches for adults and children over the age of one, and 1.5 inches for infants (under the age of 1 year old);
o
Allow the chest to completely recoil between compressions to ensure that the heart can completely refill;
o
Do not interrupt compressions except to use an AED or change providers – even at those times, perform the actions quickly to minimize interruptions;
o
Prevent over-inflation of the lungs by avoiding rapid ventilations;
o
Perform CPR as a team to perform activities more quickly and to ensure the victim receives definitive care as quickly as possible.
The time for pulse checks has been shortened since it is not always possible to know if you can feel a pulse. Do not delay CPR for more than 10 seconds if you are not sure that a pulse is present.
A manual defibrillator is preferred for infants, but if one is not available an AED should be used. If a pediatric dose attenuator is available on the AED, use it. If the dose attenuator is not available, use an adult AED for a victim of any age.
BLS for Adults
The BLS process for adults teaches one rescuer CPR but also recognizes that there may be more rescuers available to help. In the BLS course, students learn both one and two rescuer CPR. The steps for BLS for adults will depend on whether or not One Rescuer Adult BLS
Pull victim out of water or traffic
Secure the scene
Unresponsive and abnormal respirations
No respirations or Only grasping breathing
Activate the Emergency System
Get AED
Pulse Present?
NO
YES
Continue to Monitor
Perform CPR
Perform cycle of 30 compressions And 2 breaths Every 2 minutes
Connect to AED; shock when indicated
Figure 4: Adult BLS
One Rescuer CPR
Once the assessment is complete and you have determined that the victm is not responsive, does not have a pulse and is not breathing, it is important to start CPR.
Victim should be face up on a flat hard surface
If head or neck injury is possible, keep the head and neck in alignment
Kneel at victim’s side
Position the heels of your hands one on top of the other on the lower half of the breastbone
Rate = At least 100 per minute Depth = At least 2 inches
With your arms straight, push hard and fast
Allow chest to recoil between each compression
Head Tilt - Chin lift f or jaw (thrust) and deliver 2 slow breaths over 1 second each
Each round of CPR consists of 30 compressions And 2 breaths
Resume compressions
Figure 5: One Rescuer CPR
Do not interrupt compressions until AED is available
Two Rescuer Adult BLS/CPR With the 2010 BLS guidelines, it is recognized that often there will be more than one person available to perform CPR. The steps of CPR do not change, but the tasks can be shared by the team. If a second person is available:Many times, there will be a second person available who can act as a second team member. Send this person to call EMS and find an AED while you begin CPR. When the second rescuer returns, the CPR tasks can be shared:
Send the second person to activate the emergency response system and retrieve an AED if one is readily available. At the same time, the first rescuer begins CPR.
When the second rescuer returns, have them prepare the AED for use. The first person continues CPR counting compressions out loud.
When the AED is open and ready, stop CPR long enough to apply the pads (see the AED section below).
The second rescuer ensures that the victim’s airway is open then gives 2 rescue breaths over 1
second each.
The rescuers should switch positions every 2 minutes (5 cycles of 30 compressions and 2 breaths).
Once the AED is prepared, stop CPR long enough for the AED to analyze the rhythm. (See the AED section below)
Adult Mouth-to-Mask Ventilation When performing one rescuer CPR, rescue breaths should be supplied using a mask if available. 1. Perform 30 high quality compressions at least 100 per minute and 2 inches deep. 2. Seal the mask against the victim's face by forming your hand in a “C” shape and pressing down on the top and bottom edges of the mask. 3. Unless you think the victim may have a neck injury, open the airway using the head ti lt/chin lift. 4. Give two slow deep breaths over 1 second each and watch for the rise of the victim’s chest.
Adult Bag-Mask Ventilation in 2-Rescuer CPR If two or more rescuers are available with a bag-mask device, one rescuer should continue compressions while the second rescuer seals the mask over the victim’s face and delivers two rescue
breaths after every 30 compressions.
Use of the Automated External Defibrillator (AED) One of the most common causes of cardiac arrest is ventricular fibrillaton. The Automated External Defibrillator (AED) is the most eff ectve treatment for this disorder. The AED analyzes the heart rhythm and advises a shock only when it is appropriate based on what is happening in the heart. The AED is safe for anyone to use since it will talk you through the process and will not allow you to make a mistake. All AEDs work in very much the same way, so learning the algorithm below will ensure that you can safely use any AED. Get the AED and turn it on; Listen to and follow the verbal instructions
Feel for hard lumps in the upper chest; do not place the pads over these lumps
Peel the backing o ff the pads and apply to the victim’s chest
Place one pad on the upper right chest; Place the 2nd pad under the left armpit by the left nipple
Ensure that the pads are attached to the AED box
Clear everyone away from the victim; Allow AED to analyze rhythm
YES
Call out “Clear” and press shock button
Shock Advised?
NO
Continue CPR for 2 minutes
Figure 6: Using an AED for Adults
AED Use for Infants and Children Research indicates that an AED should be used as early as possible in any arrest situation for any age. If the AED has pediatric pads and a pediatric attenuator, that is ideal for an infant or child. If these pediatric pads are not available, adult pads can be used as long as they are applied so that they do not touch each other. If the AED has a pediatric attenuator available, use it for children less than 8 years old. Typically, you will see an adult/pediatric switch if the attenuator is available. If this switch is not available, use the AED to deliver an “adult” shock.
BLS for Children (Age 1 to Puberty) BLS for children and adults is very similar but there are differences. The primary differences are: Guideline Compression to breath ratio for 2 rescuers Compression to breath ratio for 1 rescuer CPR Compression depth Activate the Emergency Response System in unwitnessed arrest Activate the Emergency Response System in witnessed arrest
Adult 30 compressions: 2 breaths 30 compressions: 2 breaths Always use 2 hands for compressions At least 2 inches
Child 15 compressions : 2 breaths 30 compressions: 2 breaths
Immediately
For small children, may use one hand for compressions 1/3 of the depth of the chest (usually about 1½ to 2 inches) After performing CPR for 2 minutes
Immediately
Immediately
Figure 7: Differences in BLS for Adults and Children
One Rescuer BLS for Children
If you are alone and a child older than 1 year old is unresponsive, follow the one rescuer algorithm for children:
Pull victim out of water or traffic
Secure the scene
Unresponsive and abnormal respirations
No respirations or Only grasping breathing
Yell for help
Pulse Present and greater than 60/minute?
Feel for Carotid or Femoral pulse
YES
NO
Perform CPR For 2 minutes
Continue to Monitor
If help is not available, leave the child to get help and an AED
Perform cycle of 30 compressions And 2 breaths Every 2 minutes
Connect to AED; shock when indicated
Figure 8: One Rescuer BLS for Children
Two Rescuer BLS for Children If two rescuers are available, use the same algorithm as for one rescuer BLS with the following exceptions:
As soon as it is determined that the child is not breathing and responsive, the second rescuer should immediately activate the Emergency Response System and go to find an AED.
As soon as another rescuer arrives, change the compression to ventilation ratio from 30:1 to 15: 2 (i.e., give 2 breaths after every 15 compressions)
Child Ventilation Adult masks should not be used for small children. If the mask covers the eyes or chin of the child, it is too big and ventilations will not be optimal. Breaths for a child will typically not be as deep, but should be over 1 second each and should result in a visible rise of the child’s chest. Unless a neck injury is
suspected, open the airway using the head tilt/chin lift technique.
BLS for Infants (0 to 12 months old) BLS for children and infants is similar but there are differences. The primary differences are: Guideline Checking the pulse CPR
Compression depth
Activate the Emergency Response System in unwitnessed arrest Activate the Emergency Response System in witnessed arrest
Child Carotid or femoral artery
Infant (0 to 12 months) Brachial artery on inside of upper arm For small children, may use May use 2 fingers or 2 thumbs by one hand for compressions the encircling hands technique if your hands are big enough to circle the infant’s chest 1/3 of the depth of the 1/3 of the depth of the chest chest (usually about 1½ to (usually about 1½ inches) 2 inches) After performing CPR for 2 After performing CPR for 2 minutes minutes Immediately
Immediately
One Rescuer BLS for Infants
If you are the only rescuer of an infant, follow the one rescuer algorithm:
Pull victim out of water or traffic
Secure the scene
Unresponsive and abnormal respirations
No respirations or Only grasping breathing
Yell for help
Pulse Present and greater than 60/minute?
Feel for brachial pulse
NO
YES
Perform CPR For 2 minutes
Continue to Monitor
If help is not available, leave the child to get help and an AED
Perform cycle of 30 compressions And 2 breaths Every 2 minutes
Connect to AED; shock when indicated
Figure 9: One Rescuer Infant BLS
Two Rescuer BLS for Infants If two rescuers are available, use the same algorithm as for one rescuer BLS with the following exceptions:
As soon as it is determined that the infant is not breathing and responsive, the second rescuer should immediately activate the Emergency Response System and go to find an AED.
As soon as another rescuer arrives, change the compression to ventilation ratio from 30:1 to 15: 2 (i.e., give 2 breaths after every 15 compressions)
CPR with an Advanced Airway An advanced airway includes supraglottic airways, laryngeal mask airways, or endotracheal tubes. These airways should be initiated as soon as available since they provide a better way of providing ventilations for any age. If these advanced airways are not available, continue to use mouth-to-mouth, mouth-to-mask, or bag-mask for breathing in an arrest situation. If an advanced airway is in place, the compression/breath ratio should be as below. Guideline Adult Compression to Breath Ratio Child or Infant Compression to Breath Ratio
No Advanced Airway 30 compressions : 2 breaths 15 compressions : 2 breaths
With Advanced Airway Continue CPR without pausing; deliver 1 breath every 6 – 8 seconds (8-10 breaths per minute)
Figure 10: Compression to Breath Ratios with/without Advanced Airway
Mouth-to-Mouth Rescue Breathing If a mask or advanced airway is not available, be ready to provide mouth-to-mouth rescue breathing during CPR. Avoid over-ventlaton which can fill the stomach with air and prevent proper lung expansion. Adult and Older Children Mouth-to-Mouth
Do not give breaths too rapidly or too forcefully; doing this may cause air to be forced into the stomach resultng in distenton and less room for lung expansion. Open the airway using the head tilt/chin lift technique If head or neck injury is possible, keep the head and neck in alignment and use the Jaw thru st technique Close the victim’s nose by pinching it closed
Place your mouth over the victim’s mouth and form a tight seal
Blow into the victim’s mouth for 1 full second and watch for chest rise
NO
Reposition victim’s head
Chest rises?
YES
Give 2nd breath
Resume compressions
Figure 11: Adult & Older Child Mouth to Mouth
Infant Mouth-to-Mouth or Mouth-to-Nose Ventilation techniques for an infant is exactly like for children and adults with the fol lowing exceptions: If the infant is small enough and you can cover the nose and mouth with your mouth and create
a good seal, you do not have to pinch the nose. Be aware that an infant’s lungs are very small so a smaller volume of air will be necessary to
inflate the infant’s lungs. Every breath should still be given over 1 second but the volume will
be less.
Rescue Breathing Early recognition of and intervention for respiratory distress may prevent deterioration into cardiac arrest. During assessment, if the victim has a strong pulse but has ineffective breathing, open the airway using the head tilt/chin lift technique and begin rescue breathing. Victim Age
Breathing Rate
# Breaths/Minute
Lenth of Breath
Evaluation
Adult
Every 5-6 Seconds
10-12 per Minute
Each breath
Check for chest
Child or Infant
Every 3-5 Seconds
12-20 per Minute
should be given
rise and
over 1 second
breathing; Check pulse and begin CPR if victim becomes pulseless
Figure 12: Rescue Breathing
Relief of Choking If a victim is choking, the condition may deteriorate into respiratory arrest and cardiac arrest. Early and proper intervention can prevent this series of events. Proper intervention depends on the age of the victim and the amount of obstruction of the a irways.
Choking in an Adult or Child Older than One Year Amount of Airway Obstruction Mild
Symptoms
Breathing may be accompanied by wheezing Coughing and making noise
Recommended Actions
Severe
Exhibiting universal sign of choking (holding neck and throat) Weak or absent cough May be making highpitched noise but unable to talk Ineffective or no breathing Skin may be blue around lips and finger tips
Remain with victim and continue to monitor Encourage the victim to cough Call EMS if choking gets worse Attempt abdominal thrusts to relieve obstruction If you see the obstruction in the victim’s mouth and can remove it, do so. Do not perform blind sweeps of the mouth. Call EMS Begin CPR if victim is unresponsive and pulseless
Figure 13: Adult and Child Airway Obstruction
Abdominal Thrusts (Heimlich Maneuver) If the choking victm older than one-year-old is responsive, perform abdominal thrusts in an aempt to relieve choking. Stand behind the choking victim Do not use this technique if the victim is not responsive Wrap your arms around the victim’s waist
Place the fist of one hand in the middle of the victim’s abdomen above the navel.
Hold your fist with the other hand and exert pressure into the victim’s belly up toward his chest
NO
Obstruction Relieved?
YES
Monitor Victim
Figure 14: Abdominal Thrusts for Adult/Child Choking
Choking in Infants (Less than one year old) Amount of Airway Obstruction Mild
Symptoms
Breathing may be accompanied by wheezing Coughing and making noise
Recommended Actions
Severe
Exhibiting universal sign of choking (holding neck and throat) Weak or absent cough May be making highpitched noise but unable to talk Ineffective or no breathing Skin may be blue around lips and finger tips
Remain with infant and continue to monitor Do not do a blind finger sweep in an attempt to remove an obstruction Call EMS if infant begins to deteriorate Attempt back blows/chest thrusts to relieve obstruction If you see the obstruction in the victim’s mouth and can remove it, do so. Do not perform blind sweeps of the mouth. Call EMS Begin CPR if infant becomes unresponsive and pulseless
Figure 15: Infant Airway Obstruction
In an infant less than 12 months old who is choking but responsive, aempt to use back blows and chest thrusts to relieve an obstructon.
Sit with the infant in your lap Do not use this technique if the victim is not responsive
With your forearm resting on your thigh, rest the infant face down on your forearm His head should be lower than his chest
Avoid pressure on the infant’s throat; support the infant’s head and neck
Deliver 5 back blows between the infant’s shoulder blades
Turn the infant face up on your other forea rm with his head lower than his chest
Using 2 fingers of your free hand, deliver 5 chest thrusts over the bottom half of the breastbone
NO
Obstruction Relieved?
YES
Monitor Victim
Figure 16: Back Blows/Chest Thrusts for Choking Infant
