Upon completion of Basic life support and cardiopulmonary resuscitation (BLS & CPR) you will learn these major questions:
- Demonstrate rescue breathing for adults, children and infants using a mannequin, with and without foreign body airway obstruction.
- Describe and demonstrate CPR in adults, children and infants using a mannequin.
- Describe and demonstrate two-rescuer CPR for adults and infants using a mannequin.
- List two causes of partial or total upper airway obstruction and demonstrate Pre-hospital management for these.
1. Heart and Lung Function and Anatomy
1.1: The Cardiovascular System
The cardiovascular system consists of the the heart (cardiovascular) lungs (pulmonary), and arteries, veins, coronary and portal vessels (systemic).. The heart is a muscular organ, approximately the size of a fist, and is located in the thoracic cavity behind the sternum and between the lungs. The coronary arteries are special arteries that supply blood to the heart muscles themselves.
The function of the heart is to pump for the movement of blood through the body. The upper side of of heart receives oxygenated blood from the lungs and pumps it to the body through the arteries. The lower side
receives, through the veins, the blood that has circulated through the body and pumps it to the lungs to be oxygenated once again.
See also: Basic Medical Training Course
1.2: The Respiratory System
The respiratory system is made up of following components:
- The lungs
- The muscles & respiration
The Alveoli are surrounded by Alveolar sac. The brain sends nerve signals to muscles in the thorax and diaphragm, causing us to breathe. With each inhalation, air is carried through the airways to the Alveoli in the lungs, where oxygen and carbon dioxide are exchanged.
In combination with the respiratory system, the circulatory system supplies the oxygen necessary for life, and eliminates carbon dioxide from the body.
Adequate breathing is characterized by:
- Chest and abdomen rise and fall with each breath..
- Air can be heard and felt exiting the mouth and or nose
Inadequate breathing is characterized by:
- Inadequate rise and fall of the chest
- Noisy breathing: bubbles, rales, strider, whistling, etc
Absent breathing is characterized by: No chest or abdominal movement
Air cannot be heard or felt exiting the mouth or nose
Definition: a bluish coloration of the skin and mucous membranes caused by a lack of oxygen in the blood and tissues.
This condition can be the result of the patient breathing in an environment poor in oxygen, suffering from illness or respiratory injury, or airway obstruction.
Cyanosis can be more easily noticed on the lips, ears and nostrils or nailbeds. In patients with dark pigmentation, it is necessary to inspect the nostrils, palms and nailbeds, and the mouth and tongue.
4. Clinical and Biological Death
The respiratory and circulatory system are connected to each other,
if either one stops, the other will do the same in a very short time. The brain is the first organ to suffer the effects of a lack of oxygen. Shortly after oxygen supply is cut off, brain cells begin to die, causing irreversible damage.
Clinical death: Occurs when a patient is in respiratory arrest
(not breathing) or in cardiac arrest (heart not beating). The patient has a period of 4 to 6 minutes to be resuscitated ^without brain damage. Clinical death can be reversed.
Biological death: The moment the brain cells begin to die. Biological death cannot be reversed.
EXCEPTION: An exception to the rule may be cold-water drowning. There have been cases of persons resuscitated one hour or more after cold-water drowning. Cold-water drowning victims should receive prolonged resuscitative efforts. In a cold environment, a person should not be considered dead until the victim’s body is warmed.
5. Signs of Certain Death
Only a doctor can pronounce a person officially dead.
See also: About Medical First Responder
6. Techniques for Opening the Airway
When opening the airway, use the correct method:
Medical case: Head-tilt chin-lift
Trauma case: Jaw thrust maneuver
6.1 Head-Tilt Chin-Lift
This is the method of choice for opening the airway.
- Position the patient lying__________________
- Kneel by the patient’s shoulders toward the head.
- Place one hand on the____________ and place the fingertips of your other hand under the_____________ part of the patient’s jaw.
- Lift up on the chin, supporting the jaw. and at the same time, tilt the head back as far as possible. In this position, chin should be the highest point of head.
For infants and children: Place in the “sniffing” position — do not over-extend.
- Always keep the patient’s mouth slightly open – use your thumb to hold down the patient’s lower lip.
- Never dig into the soft tissue under the patient’s chin.
Once the airway is open, check breathing. Look, listen and feel. If patient is not breathing, two rescue breaths for 1 second each should be started. If unable to ventilate, assume the airway is obstructed۔
6.2 Jaw Thrust
The jaw thrust is the only manoeuvres recommended on an unconscious patient with suspected head, neck or spinal injury.
- Position the patient lying face up.
- Kneel above the patient’s head. Place your elbows next to the patient’s head on the surface where the patient is lying. Place both hands on either side of the patient’s head.
- Grasp the angle of the patient’s jaw on both sides. For an infant or child use two or three fingers.
- Use a lifting motion to move the jaw forward (up) with both hands.
- Keep the patient’s mouth slightly open by using your thumbs if needed.
7. Artificial Ventilation (Rescue Breathing)
Once the patient has an open airway, you can provide artificial ventilation for a patient breathing inadequately or not at all.
How is it possible to maintain a patient alive with exhaled air? Natural air contains approximately 21% oxygen and the body only utilises about 5%. Therefore, exhaled air contains 16% oxygen. This exhaled air can resuscitate a person who is not breathing, until a high-concentration oxygen source is available.
There are many techniques for artificial ventilation. You should become competent in three. Fill in the blanks below in proper order of preference:
Breathing rates and duration
- Adults: 10-12 breaths per minute lasting 1.5-2 seconds.
- Children and infants: 20 breaths per minute lasting 1-1.5 seconds.
- Newborns: 40 breaths per minute lasting 1-1.5 seconds.
Look for proper chest rise. With infants and newborns, use puffs from the mouth so as not to over ventilate.
7.1 Mouth-to-Mask Ventilation
This method uses a pocket face mask with a one-way valve to form a seal around the patient’s nose and mouth. It is the preferred method because it eliminates contamination with the patient and prevents exposure.
- Place the mask around the patient’s mouth and nose. The narrower top portion of the mask should be seated on the . The broader portion should fit the chin.
- Seal the mask by placing heel and thumb of each hand along the border of the mask and compressing firmly to provide a tight seal around the edges of the mask.
- Open the patient’s airway, using the appropriate manoeuvre.
- Give breaths at the appropriate rate and depth, observing and Listen for patient exhalation.
7.2 Mouth-to-Barrier Device Ventilation Procedure
There are two broad categories of barrier devices:
Face Shields and Pocket Masks. Most have a one-way valve but have no exhalation port. The patient’s exhaled air will leak out around the barrier device.
- Position the barrier device around the patient’s mouth and nose, providing
- Open the patient’s airway, using the appropriate manoeuvre.
- Deliver breaths at the appropriate rate and depth, observing chest rise and fall. Listen for patient exhalation.
7.3 Mouth-to-Mouth Ventilation Procedure
The risk of contacting infectious diseases makes mouth-to-mouth ventilation very risky for use in the field. The decision to use this method is a personal one. Use barrier devices whenever possible.
- Open the patient’s airway, using the appropriate manoeuvre.
- Gently pinch the patient’s nose closed with your thumb and index finger (of the hand on the forehead), to prevent__________________
- Take a deep breath and seal your lips around the patient’s mouth, providing an adequate seal. If ventilating an infant or small child, cover both the mouth and nose with your mouth.
- Deliver breaths at the adequate rate and depth.
Stoma Patients: Occasionally, you may encounter a patient who has undergone a laryngectomy. This person will have a “stoma,” a permanent opening from the trachea to the front of the neck. Perform direct mouth-to-stoma ventilation.
See also: About Incident & types
This problem can occur during rescue breathing, which can force some into the patient’s stomach, causing the stomach to become inflated, or distended. This can result in two serious problems:
- Reduced lung volume
- Vomiting, resulting in possible airway obstruction or aspiration (causing lung damage and/or a lethal form of pneumonia)
Prevention: Avoid or minimize gastric distention by positioning the patient’s head properly and by avoiding giving ventilations.
When gastric distention presents, be prepared for vomiting. If the patient does vomit, roll the patient (entire human body) onto his or her side, manually stabilising the head and neck. Be prepared to clear the patient’s mouth and throat with gauze and gloved fingers. Apply suction per local protocol. Place the patient in the recovery position, as discussed next.
Hazards to rescuers
- Diseases: Blood-borne and/or airborne. Mask, gloves, and eye protection should be worn.
Use a bag-valve mask (BVM) or pocket mask (these items will be discussed in Lesson 8).
- Chemicals: Exposure from a contaminated patient. Patient should be decontaminated first.
- Vomitus: One-way valve on a pocket mask or BVM should be used.
Begin with two slow and deep ventilations Continue with one ventilation every 5 seconds for an adult, lasting 1.5 to 2 seconds each.
Mouth to mouth ventilation
Mouth lo Mouth And Nose ventilation
Mouth Too Stoma Ventilation
8. Chain of Survival
Cardiopulmonary resuscitation (CPR) can save the lives of victims in cardiac arrest. Two-thirds of heart attack victims (due to heart disease) die outside the hospital, most within two hours of the onset of symptoms.
Though CPR itself is not enough to
save the life of a victim of heart
attack, it is a vital link in the chain of survival.
The “Chain of Survival” has five links, and the patient’s chances for surviving are the greatest when all the links come together.
- Early access.
- Early CPR
- Early defibrillation
- Early advanced care
- Integrated post-cardiac arrest care
The need for these interventions should not be limited to victims of heart disease. Many victims of drowning, trauma, electrocution, suffocation, airway obstruction, allergic reaction, etc., may be saved by prompt intervention.
9. Heart Attack Risk Factors
Risk factors that can be changed
- High blood pressure
- High blood cholesterol
- Diabetes and prediabetes
- Being overweight or obese
- Having a history of preeclampsia during pregnancy
- Unhealthy diet
- Being physically inactive
Risk factors that cannot be changed
- Increasing Age
- Male gender
- Heredity (including race)
10.Cardiopulmonary Resuscitation (CPR)
When respiratory arrest occurs, the heart can continue to pump for several minutes and circulate oxygen. Without early intervention, respiratory arrest may lead to cardiac arrest. Once cardiac arrest occurs, circulation ceases and vital organs are deprived of oxygen.
When respiratory and cardiac arrest occurs together, the patient is
considered in clinical death. Within 4 to 6 minutes
without circulation, brain damage will begin, and after 8 to 10 minutes, the damage is irreversible.
CPR involves a combination of chest compressions and artificial ventilations designed to revive a person and prevent biological death by mechanically keeping a person’s heart and lungs working.
CPR MUST BE STARTED AS SOON AS POSSIBLE
10.1Preparing for CPR
No patient should undergo CPR until the need for resuscitation has been established by appropriate patient assessment. Before providing CPR you must determine unresponsiveness and breathlessness . Follow these steps:
- Establish unresponsiveness. Ask the patient, “_____________ ?”
or s’nake/tap the patient. If unresponsive, position the patient
properly (must be supine with arms along the body on a firm, flat surface, or blood flow will be compromised).
2. Activate the EMS system. (Ask someone else to activate when available).
3. Perform C-A-B.
INFANT: 0 to 1 year Old
CHILD: 1 to 8 years old
10.2 CPR Chest Compressions for Adults
Cardiac arrest in children is rarely caused by heart problem. Usually the cause is because of too little oxygen.. Chest compressions consist of rhythmic, repeated pressure over the lower half of the sternum. When combined with artificial ventilation, it provides enough blood circulation to sustain life. Follow these steps:
1) Position the patient. Must be supine on firm, flat surface, with arms
2) Expose the patient’s chest. Remove the patient’s shirt (male only), providing for patient’s privacy as much as possible.
3) Get in position. Kneel close to the patient’s side, your body centered with the patient’s sternum and your knees about as wide apart as your shoulders.
4) Locate the compression site. Place your hand in the centre of chest between the nipples.
5) Position your hands. For adult put your free hand on top of the first hand. Extend or interlace your fingers (do not rest them on the chest wall). For children when using 2 hands, heel of one hand with second on top or with heel of one hand only.
6) Position your shoulders. They should be directly over your hands.
7) Perform chest compressions. Keeping your arms and your elbows , thrust
straight downward from your shoulders. Release pressure completely after each compression. However, do not lift or move your hands, or you will lose proper position. Count as you perform compressions.
Adult CPR Summary: 9 years and older
Compression depth: at least 2 inches (5 cm)
Compression rate: at least 100 per minute
Each ventilation: 1 second
Pulse location: carotid artery
One Rescuer Cycle: 30 Compression 02 Breaths
Hand position for adult chest Compression
10.3 CPR Chest Compression’s for Children and Infants
Cardiac arrest in infants is rarely caused by heart problems. Usually the cause is too little oxygen (hypoxia) due to injuries, suffocation, smoke inhalation, etc. For this reason, you should resuscitate an infant for two minute before activating the EMS system (if you are alone).
1) Position the patient. Must be supine on firm, flat surface, with arms along sides. If an infant, place him or her on your forearm, using your palm to support the head.
2) Expose the patient’s chest. Remove the patient’s shirt or blouse.
3) Locate the compression site. In a child, use the same location as an adult. In infants, use one finger width below an imaginary line between the nipples.
4) Perform chest compression’s. Use the flat part of your middle and ring fingers to compress the sternum. Release pressure
completely after each compression. However, do not lift or move your hands, or you will lose proper position. Count as you perform compressions.
Child CPR Summary: 1-8 years of age
Compression depth: at least 1/3 anterior-posterior diameter or about 2 inches (5 cm)
Compression rate: at least 100 per minute
Each ventilation: 1 second
One-rescuer cycle: 30 compression’s, 2’breaths
Hand positioning for child chest compressions
Infant CPR Summary – 1 year old and under
Compression depth: at least 1/3 anterior-posterior diameter or about 1 1/2 inches (4 cm)
Compression rate: at least 100 per minute
Each ventilation: 1 second
One-rescuer cycle: 30 compressions, 2 breaths
11. Special Considerations Regarding CPR
11.1 Signs of Successful CPR
“Successful” CPR does not mean that the patient survives – it only means that you performed it correctly. Very few patients will survive if they do not receive advanced cardiac life support (ACLS). The goal of CPR is to prevent the death of cells and organs for a few crucial minutes. The patient’s condition needs to be monitored throughout CPR to determine if CPR is effective.
- Have someone feel for a pulse during compressions. A pulse should be palpable with every compression.
- The chest should rise and fall with each ventilation.
- The pupils may begin to react normally.
- Patient’s skin colour may improve.
- Patient may attempt to move and try to swallow.
- Heartbeat may return.
11.2 When Not to Begin CPR
There are special circumstances under which CPR should not be initiated even when the patient has no breathing. You should not initiate CPR when any of the signs of certain death, mentioned earlier, are present.
11.3 Complications Caused by CPR
Even properly performed CPR can cause injuries, including:
- Fracture of the sternum and ribs
- Cuts and bruises to the lungs
- Lacerations to the liver.
Most of these complications are rare. Take care to use proper technique. Remember that even if CPR results in complications, the alternative is death.
11.4 Mistakes in Performing CPR
|Mistakes in Performing CPR|
|Patient is not on a hard surface||Compressions are not effective|
|Patient is not in horizontal position||If patient ‘s head is higher than the rest of the body , there is insufficient blood flow to reach the brain|
|Head -tilt chin-lift manoeuvre improperly performed||Open airway not ensured|
|Incomplete sea I around the patient’s mouth and /o r n o se||Ventilation are not effective|
|Nostrils not completely pinched and the patient’s mouth is not fully open during mouth -to- mouth ventilation||Ventilation are not effective|
|Hands not in correct position or compressions incorrectly placed||Fractured rib s; fractured sternum; lacerated liver, spleen, lungs o r injured pleura as a result o f fractured ribs|
|Compressions too deep or frequent||Insufficient amount of blood is pumped|
|Inadequate oxygenation of blood|
11.5 Interrupting CPR
Once you begin CPR, you should not interrupt for more than a few seconds to check for breathing, or to reposition yourself or the patient. In addition, you interrupt CPR to:
- Move the patient onto a stretcher
- Move the patient down a flight of stairs or through a hallway
- Loading or unloading the patient into the ambulance
- Allow for defibrillation or ACLS measures to be initiated
- Recover from physical exhaustion
12. Recovery Position
For a patient with a pulse and adequate breathing, place the patient in the recovery position. This position uses gravity to keep the airway clear, allowing fluids to drain out of the mouth instead of into the airway.
The recovery position should be used on an unresponsive, uninjured patient who is breathing adequately.
Keep the patient in that position until transportation arrives.
Do not move the patient into the recovery position if you suspect trauma or C-spine injury
Placing the patient in the recovery position
- Lift the patient’s left arm above his head and cross his right leg over the left leg.
- Support the patient’s face as you grasp his right shoulder.
- Roll the patient toward you onto his side (preferably the left side). Then place his right hand under the side of his face. If possible, move the patient’s head, shoulders, and torso simultaneously as a unit without twisting. The head should be in as close to a midline position as possible.
- Flex the patient’s top leg slightly at the knee.
13.Foreign Body Airway Obstruction (FBAO)
11.3 Causes of Airway Obstruction
There are upper and lower airway obstructions. An upper airway obstruction is anything that blocks the back of the mouth or throat, or the nasal passages. A lower airway obstruction is caused by breathing in a foreign body or by severe spasm of the bronchial passages, such as asthma. Airway obstruction can be caused by the following:
- Foreign body
- Tissue damage
The most common airway obstruction in a responsive patient is unresponsiveness , and in the unresponsive patient it is the
cardiopulmonary arrest . The focus of this lesson is primarily on removing
upper foreign body airway obstruction.
13.2 Recognizing FBAO
The key to successful treatment is early recognition. Suspect FBAO in any victim who suddenly stops breathing, becomes cyanotic, and loses consciousness for no apparent reason.
There are two types of FBAO – Partial and complete.
Partial: An object caught in the throat that does not totally block breathing. A patient with partial obstruction may have adequate or poor air exchange. With adequate air exchange, the patient may cough forcefully, though there may be wheezing between coughs. Do not interfere with patient’s attempt to clear the airway. With poor air exchange, the patient will exhibit a weak, ineffective cough, high-pitched noise while inhaling, increased respiratory difficulty and possible cyanosis. Treat this situation as a complete airway obstruction.
Complete: The patient is unable to speak, breathe or cough. May clutch the neck with thumb and finger – this gesture is known as
the complete Obstruction.
Air movement will be absent.
14.Managing FBAO in Adults and Children
The method recommended for relieving FBAO with poor air exchange or complete obstruction is the abdominal thrust (Heimlich manoeuvre). Each individual thrust should be administered with the intent of relieving the obstruction. It may be necessary to perform several thrusts. It is possible to damage internal organs with this method. To minimize the possibility of injury to the patient, never place your hands on the xiphoid process or on the lower edges of the rib cage. Your hands should be below this area but above the navel.
Manage a complete airway obstruction in children the same way you would for adults. Airway obstructions in children may also be caused by infections such as epiglottitis or croup, which produce airway oedema. Suspect this condition if an infant or child has a fever with congestion, hoarseness or drooling A patient with any of these conditions must be transported to the emergency facility. It is dangerous to the patient to attempt to relieve this form of obstruction.
You must be able to see the foreign body first before
14.1 Responsive Adult/Child (patient standing or sitting)
- Take BSI precautions. Introduce yourself and ask permission.
- Determine if the obstruction is complete or partial obstruction with poor air exchange. Ask, “Are you choking?” or “Can you speak?”
- If partial obstruction, encourage the patient to cough, if unable to cough, go to step 4.
- Get in position. Stand behind the patient. Place one leg between the patient’s legs to obtain a stable position.
- Position your hands. Reach around with one hand to locate the patient’s navel. Make a fist with one hand, place the thumb-side of the fist against the patient’s abdomen, slightly above the navel and below the xiphoid process.
- Perform an abdominal thrust. Grasp your fist with the other and give up to 5 abdominal thrusts in rapid succession.
- Repeat thrusts until the object is expelled from the airway or the patient becomes unconscious. Each new thrust should be a separate and distinct movement.
If the patient becomes unresponsive before you are able to clear the airway obstruction, direct someone to call EMS and begin CPR.
14.2 Unresponsive Adult or Child / Obese or preg (patient lying down)
- Position the patient
- Tap and shout to assess responsiveness. If unresponsive., activate EMS.
- Get in position (as in CPR). Begin CPR with chest compressions (without a pulse check).
- After 30 compressions, open airway using appropriate technique. If object is seen, remove object from patient’s mouth by finger sweep. Use the tongue-jaw lift to open the patient’s mouth. Insert the index finger of the other hand along the inside of the cheek into the throat, using a hooking action to dislodge the foreign body and lift it out.
DO NOT use finger sweep on unresponsive patients who have a gag reflex.
5. Attempt to give ventilation. If there are no signs of breathing, give one slow breath (first ventilation). If unsuccessful, the patient’s head and try again (second ventilation).
6.If after 2 attempts of ventilation you are not able to achieve chest rise, continue CPR.
14.3 Pregnant or Obese Responsive Adult (patient standing or sitting)
Chest thrusts are to be used only with patients in late stages of pregnancy or with the markedly obese, when abdominal thrusts cannot be applied effectively.
- Determine if the obstruction is complete or partial obstruction with poor air exchange. Ask, “Are you choking?” or “Can you speak?”. If partial obstruction, encourage the patient to cough. If unable to cough, go to next step.
- Get in position. Stand behind the patient, with your arms directly under the patient’s armpits, and encircle the patient’s chest.
- Position your hands. Place the thumb-side of your fist along the patient’s sternum, avoiding the xiphoid process and margins of the rib cage.
- Perform a chest thrust. Grab your fist with the other hand and perform 5 chest thrusts in rapid succession. Oserve for evidence that the object has been removed.
- If the patient’s airway remains obstructed, repeat the thrusts until the object is expelled from the ainyvay or the patient becomes unconscious.
- If the patient becomes unresponsive before you are able to clear the airway obstruction, activate the EMS and begin CPR.
15.Managing FBAO in Infants
Always suspect foreign body ain^vay obstruction in infants who demonstrate a sudden onset of respiratory distress associated with gagging, coughing or wheezing. Most common causes are
eating coin or inhaling small balls. As mentioned earlier, airway obstructions may also be caused by
airway obstructions may also be caused by. Suspect this condition if the infant has a fever with congestion, hoarseness or drooling. Do not attempt to relieve this form of obstruction and transport the patient immediately.
15.1 Removing FBAO in a Conscious Infant
Perform the following procedures only if the infant has a complete obstruction or partial obstruction with poor air exchange, and only if you suspect a foreign object.
1) Verify complete airway obstruction. Serious breathing difficulty, ineffective cough, no strong cry.
2) Position the infant. Straddle the infant face-down over one of your forearms, head_______ than the body. Support the infant’s head by holding the jaw with your hand.
3) Deliver 5 back blows. Use the heel of your hand between the shoulder blades. If foreign object is not expelled, position the infant on your arm, head lower than the body.
4) Deliver 5 chest thrusts. Position your middle and ring fingers in the middle of the infant’s sternum, just below the imaginary line between the infant’s nipples. Use a quick downward motion.
5) Repeat steps 2 to 5 until effective, or until infant becomes unconscious.
6) Begin CPR when the infant becomes unconscious.
15.2 Removing FBAO in an Unconscious Infant
1) Establish unresponsiveness. If unresponsive, direct someone
to activate EMS. If you are alone, provider__________________
of rescue support before stopping to call EMS.
2) Begin CPR with chest compressions (do not perform a pulse check).
3) After 30 compressions, open airway. If you see a foreign body, remove it but do not perform blind finger sweeps.
4) Attempt to give ventilations. If there are no signs of breathing, give one slow breath (first ventilation). If unsuccessful, reposition the patient’s head and try again (second ventilation).
5) If after 2 attempts you are unable to achieve adequate chest rise, continue CPR (cycles of chest compression and ventilation’s) until object is expelled.
6) After 2 minutes, if no one has already done so, activate the EMS.