BASIC LIFE SUPPORT: HEALTHCARE PROVIDER

INTROD
UCTION

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

• Chain of Survival and the Role of the Healthcare Provider

• Clinical Presentations and Treatment of Heart Disease and Stroke

• Prudent Heart Living

• Techniques for Adult and Pediatric CPR and Use of the AED

• Pathophysiology, Treatment and Prevention of Foreign Body Airway Obstruction

• Injury Prevention in the Pediatric Age Group

• L.A. County guidelines for withholding CPR

LESSON
OBJECTIVES

At the end of this lesson the participants will be able to:

1. Describe the links in the AHA Chain of Survival, including the importance of:

• Activating the appropriate emergency response system (phoning 911 or other

response system)

• Performing CPR

• Using a barrier device

• Providing bag-mask ventilation

• Providing early defibrillation

• Ensuring the arrival of early advanced care by activating the appropriate

emergency response system (phoning 911 or other response system)

2. Describe the steps of CPR:

• When to start CPR

• When to start rescue breathing, including ventilation with a barrier device and
bag-mask ventilation (with and without oxygen)
 • How to check for normal breathing or signs of circulation

• The ABC sequence of CPR

• When and how to use an AED

• The signs of severe or complete FBAO

• How to relieve FBAO in the responsive and unresponsive victim

3. Describe the signs of 5 major emergencies in adults

• Heart attack

• Stroke

• Cardiac arrest

• Respiratory arrest

• FBAO

4. Describe strategies to prevent sudden infant death syndrome in infants and

injuries in children.

5. Using an adult, child, or infant manikin, demonstrate the following skills:

• Activation of the emergency response system (phone 911 or other appropriate

response system)

• Rescue breathing using mouth-to mouth and bag-mask ventilation (with and
without oxygen) for adult, child, and infant victims

• 1- and 2-rescuer CPR for adult, child, and infant victims

• Use of an AED for victims ≥8 years of age (and approximately 25 kg or

more)

• Relief of FBAO in the responsive and unresponsive victim of any age

SKILLS

One Rescuer: Adult, Child, and Infant CPR

Two Rescuer: Adult CPR

FBAO Conscious and Unconscious: Adult, Child, and Infant

Bag-mask ventilation

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

• Adult – Greater than eight years of age

• Child - One year to eight years of age

• Infant - Less than one year of age

• Prudent Heat Living – a lifestyle that minimizes the risk of future heart disease.

• Epigastrium - upper mid-portion of abdomen

• Nitroglycerin - a medication that acts by dilating the coronary arteries, which

increases blood flow to the heart muscle; and lowering the blood pressure and dilating
the veins, which decreases the work of the heart and the heart muscle's need for
oxygen.

• Ventricular Fibrillation - a chaotic, uncoordinated quivering of the heart muscle,

producing no heartbeat

• Pneumothorax - collapsed lung

• Hemothorax - blood in the pleural cavity

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

KEY
CONCEPTS

The following section provides information and space for taking notes on the key
concepts discussed by the instructor.

American Heart Association Statistics

• Cardiovascular disease is the leading cause of death in the U.S.

• Cardiovascular disease accounts for nearly one million deaths per

year in the U.S.

• Approximately ½ million deaths are due to acute myocardial

infarction; approximately 50% of these deaths are sudden and
occur within the first hour of the onset of symptoms

• Stroke is the third leading cause of death in the U.S. and the
leading cause of brain injury in adults

• Approximately ½ million suffer a stroke and nearly ¼ of these die

annually

Emergency Cardiovascular Care (ECC)

• Includes all responses (prehospital and in-hospital) needed to

stabilize the victim or patient who develops life-threatening events
affecting the respiratory, cardiovascular, and cerebrovascular
systems

• Ultimate goal is to maximize the outcome for all victim or

patients

• Two components of ECC are BLS and ACLS

Basic Life Support (BLS)

• Includes interventions that can rapidly be performed by trained

laypersons and healthcare providers to ensure recognition of
common emergencies, access to ACLS, adequate airway,
breathing, and oxygenation, and adequate circulation

• BLS skills include CPR, use of AED, and relief of foreign body
airway obstruction
Advanced Cardiac Life Support

Includes BLS plus the use of adjunctive equipment to support

ventilation, establishment of IV access, administration of drugs, use of
cardiac monitoring, defibrillation or other control of arrhythmias, and
care after resuscitation

CHAIN OF SURVIVAL

• Early Access

• Early CPR

• Early Defibrillation

• Early Advanced Care

First Link: Early Access

• Problem: Long 911 call-to-defibrillation intervals are common

• Key to effectiveness of this link: Recognition of early warning

signs such as chest pain and shortness of breath so that 911 is
called before collapse occurs

• Early identification of collapse can lead to rapid activation of the

EMS system, rapid dispatching and arrival of first responders who
can bring defibrillation and ACLS capabilities to the patient’s side

Second Link: Early CPR

• CPR is most effective when started immediately after collapse

• Bystander CPR has been consistently shown to have a significant

positive effect on survival

• Bystander CPR is the best treatment that a cardiac arrest patient

can receive until the arrival of defibrillation and ACLS care

Third Link: Early Defibrillation

• The link most likely to improve survival rates

• Time to defibrillation is the critical variable for successful

conversion from VF to a normal rhythm

• Every minute that passes can reduce the chance for successful
conversion by 7-10%

• Goal of early defibrillation: Within 5 minutes of EMS call receipt

to shock

Fourth Link: Early Advanced Care

• Designed to prevent cardiac arrest through the use of advanced

airway management, administration of medication, and other
interventions

• Include therapies that help resuscitate victims of cardiac arrest

who are not responding to defibrillation

• Can provide defibrillation if VF develops and helps stabilize the

patient after resuscitation

EARLY RECOGNITION OF MAJOR EMERGENCIES

CORONARY ARTERY DISEASE (CAD)

Clinical Presentation of Angina Pectoris

Angina Pectoris – a common symptom of CAD; a transient pain or

discomfort caused by an inadequate blood flow and oxygen delivery to
the heart muscle
Character:

• Described as crushing, pressing, constricting, oppressive, or

heavy

Location:

• Located behind sternum or throughout front of chest; may

radiate to shoulders, arms, neck, jaw, back of chest and upper
abdomen

Duration:

• Steady discomfort, usually lasting <15 minutes

Provoking Factors:

• Any factor that increases myocardial oxygen demand beyond

available supply, such as increased heart rate and increased blood
pressure

Relieving Factors:

• Reversal of provoking factors

• Rest

• Nitroglycerin

Unstable Angina

Angina that:

• Occurs at rest

• Wakes that patient at night

• Lasts longer than 20 minutes

Atypical Presentations of CAD

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

• Symptoms of weakness, shortness of breath, syncope, or light

headedness may be the only symptoms in diabetic patients

Clinical Presentation of AMI (or Heart Attack)

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

Character, location and duration of chest pain or discomfort is similar to

angina; usually described as more intense, however, this is not universal

Other Accompanying Signs or Symptoms

• Sweating, nausea, vomiting, shortness of breath or weakness.

Provoking Factors

• Most episodes occur at rest or with modest daily activity

• Heavy physical exertion (occurs infrequently)

• Other factors include emotional stress and illicit drug use (i.e.,
cocaine)

Relieving Factors

• Not usually relieved with rest and/or nitroglycerin

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

Actions for Survival (According to American Heart Association)

Person with unknown CAD

• Recognize the signals of a heart attack

• Stop activity and sit or lie down
• Wait about 5 minutes to see if the symptoms go away
• If pain persists, activate EMS

If no EMS available, take victim to the nearest 24-hr

hospital emergency department.

Person with known CAD (using nitroglycerin):

• Recognize the signals of a heart attack

• Stop activity and sit or lie down

• Take 1 nitroglycerin tablet at a time at 3-5 minute intervals

(maximum 3 tablets)

• If pain persists, activate EMS

If no EMS available, take victim to the nearest 24-hr

hospital emergency department.

Sudden Cardiac Death (Cardiac Arrest)

Sudden Death – occurs when the heart stops beating and breathing
ceases abruptly or unexpectedly

• May occur as the initial and only manifestation of CAD

• Most commonly occurs within one or two hours after the onset of
 a heart attack

• Most common cause is CAD

• Directly caused by ventricular fibrillation, which results in the
lack of an effective heart beat
• Best chance for survival: early CPR and early defibrillation

RISK FACTORS AND PRUDENT HEART LIVING

Risk Factors of CAD

Factors that cannot be changed:

• Heredity

• Male gender

• Race

Factors that can be changed:

• Cigarette smoking

• High blood pressure

• High blood cholesterol levels

• Physical inactivity

• Diabetes

• Obesity

• Excessive Stress

Prudent Heart Living

• Weight control

• Physical fitness

• Sensible dietary habits

• Avoidance of cigarette smoking

• Reduction of cholesterol and triglycerides in diet

• Control of high blood pressure

• Control of Diabetes
• Eliminate obesity

CEREBROVASCULAR DISEASE

Stroke
• The third leading cause of death in the U.S.
• Caused by occlusion (ischemic stroke) or rupture (hemorrhagic
stroke) of a blood vessel
• Transient ischemic attack (TIA) produces signs identical to those
of a stroke, but they last only a few minutes; indicates a future risk
of stroke
• Early detection of signs and symptoms, rapid transport and
hospital triage is necessary in order to initiate timely therapies

New Therapies

• Effective in restoring blood flow and oxygen to the brain

• May improve outcome and limit neurological insult
• To be effective, they must be initiated within 3 hours of the onset
of the stroke symptoms

Risk Factors Specific to Stroke

• Transient ischemic attacks (TIAs)

• High red blood cell count
• Heart disease

Chain of Survival and Recovery

• Early recognition and activation of EMS

• EMS response, treatment and transport
• Notification of stroke center
• Early emergency department care

Signs of Stroke or TIA

• Sudden weakness or numbness of the face, arm or leg on one side

of the body
• Loss of speech, slurred or incoherent speech
• Unexplained dizziness, unsteadiness or sudden falls
• Dimness or loss of vision, particularly in one eye
• Altered level of consciousness
• Unusually severe or sudden intense headache

General Emergency Therapy

• Maintain airway patency

• Basic airway maneuvers, airway adjuncts and suction may be
necessary
• Endotracheal intubation if basic airway maneuvers are
unsuccessful
• Positive-pressure ventilation if inadequate respirations or
respiratory arrest
• Monitor patient for seizures and treat appropriately

CARDIOPULMONARY RESUSCITATION

Indications for CPR

• Cardiac arrest
• Respiratory arrest
• Only exceptions:
• L.A. County Reference #814 –
Determination/Pronouncement of Death in the Field
• L.A. County Reference #815 – Honoring Prehospital Do-
Not-Resuscitate (DNR) Orders

Use of Automated External Defibrillator (AED)

• AEDs are considered an important and lifesaving addition to BLS

• AEDs are included in the

 sequence of BLS (to be taught
in a separate lecture)

The Sequence of BLS

Establish Unresponsiveness
• If head or neck trauma suspected, limit movement or “log-roll”

• **If no response, activate EMS system by phoning 911 or other

emergency response number

**Activate EMS system

• Adult: After determining the victim is unresponsive, exception—

near-drowning, traumatic arrests, & drug overdoses (activate EMS
after 1 minute of CPR)

• Child & Infant: Not done until after 1 minute of CPR, exception—
children known to be high risk for cardiac arrest (activate EMS
immediately after collapse)

Open Airway
• Victim should be supine

• Open airway with head tilt-chin lift maneuver

• Use jaw-thrust maneuver if head or neck trauma suspected

Assess Breathing (10 seconds)

• Look for chest rise and fall

• Listen for air escaping during exhalation

• Feel for the flow of air

Recovery Position

• Used if victim unresponsive, but breathing with signs of circulation

• A modified lateral position used to prevent the airway from being
obstructed by the tongue, mucus or vomitus

Provide Rescue Breathing

• Required if breathing is absent or inadequate

• Give 2 slow breaths using the lowest tidal volume sufficient to make
the chest rise:

Adult: Over 2 seconds

Child & Infant: Over 1 – 1 ½ seconds

Rescue Breathing Techniques:

• Mouth-to-Mouth

• Mouth-to-Nose

• Mouth-to-Stoma

• Mouth-to-Barrier

• Mouth-to-Face Shield

• Mouth-to Mask *

• Bag-mask device *

*If oxygen available, use smaller tidal volumes over 1-2

seconds.

If no oxygen available, use slighter higher tidal volumes over

2 seconds.

May use the lateral or cephalic techniques.

Cricoid Pressure

Pressure applied to the victim’s cricoid cartilage in order to compress

the esophagus between the trachea and the spine; effective in preventing
gastric inflation
Assess for Circulation (10 seconds)

• Adult & Child: Palpate carotid pulse

• Infant: Palpate brachial pulse

• If pulse present but no breathing, provide rescue breathing at a rate

of:

Adult - 1 breath every 4-5 seconds (or 10-12/minute)

Child & Infant – 1 breath every 3 seconds (or 20/minute)

Chest Compressions

• Adult: Required if no pulse present

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

• Compression Rate:

Adult, Child, & Infant – 100/min

• Compression to Ventilation Ratio:

Adult 1- and 2-rescuer CPR – 15:2

Infant and child 1- and 2-rescuer CPR – 5:1

• Proper Hand Placement

Adult: Place hands on the sternum between the nipple line

Child: Place heel of one hand over lower half of sternum

Infant: Place 2 fingers of one hand one finger’s width below the nipple
line or two-thumb encircling hands technique over the lower half of
sternum

• Depth of Compression

Adult: 1 ½ - 2 inches or enough to generate a pulse

Child & Infant: 1/3 – ½ the depth of the chest or enough to generate
a pulse
Adult: Perform 4 complete cycles 15 compressions and 2
ventilations, then recheck for signs of breathing and circulation

Child & Infant: Perform 20 cycles of 5 compressions and 1

ventilation, activate EMS, then recheck for signs of
breathing and circulation

Reassessment (10 seconds)

• Should be performed after the first minute of CPR and every few
minutes thereafter

• If no pulse, resume CPR beginning with chest compressions

• If pulse and breathing present, place in recovery position

• If pulse present but no breathing, provide rescue breathing:

Adult - 1 breath every 4-5 seconds (or 10-12/minute)

Child & Infant – 1 breath every 3 seconds (or 20/minute)

2-Rescuer CPR

Refer to skills sheet

Monitoring the Effectiveness of CPR

• Chest rise with ventilation

• Carotid or brachial pulse with compression

Complications of CPR

• Rib fractures

• Gastric inflation, with or without regurgitation

• Lacerated spleen and liver

• Fractured sternum

• Pneumothorax

• Hemothorax

• Lung contusion

• Fat emboli

Minimizing Complications

• Some of the complications may be minimized by performing CPR

 properly, such as using proper hand placement, however, they
cannot be entirely prevented

• Gastric inflation can be minimized by maintaining an open airway

and limiting ventilation volumes to the point at which the chest rises
adequately

Unique Situations

• CPR should not be interrupted except for endotracheal intubation,

when AED being applied/used, or transporting problems
• Interruptions, if necessary, should be brief and must be avoided if
possible
• If the rescuer is alone, a momentary delay may be necessary to
activate EMS

CARDIOPULMONARY ARREST IN INFANTS AND

CHILDREN

Cardiac arrest in children typically represents the terminal event of

progressive shock or respiratory failure

Common Causes

• Injuries
• Foreign-body airway obstruction
• Smoke inhalation
• Sudden infant death syndrome (SIDS)
• Poisoning
• Infections of throat and respiratory tract
• Congenital heart defect

Common Childhood Injuries

• Motor vehicle injuries

• Pedestrian Injuries
• Bicycle injuries
• Submersion
• Burns
• Firearm injuries

Injury Prevention

• Injury is the leading cause of death in children and young adults

• Prevention of these injuries would substantially reduce childhood
deaths and disability

SIDS Prevention

• SIDS typically occurs in infants 1 month to 1 year

• Increased risks associated with many factors including: prone
sleeping position, the winter months, lower family income, males,
siblings of SIDS victims
• To reduce the risk of SIDS:
• Place infants supine when sleeping
• Infants placed on their side should be supported to keep them
from rolling to the prone position
• Do not place infants on soft surfaces to sleep

FOREIGN BODY AIRWAY OBSTRUCTION

Causes of obstruction

Common causes:

Adults

• Food, especially meat

• Attempting to swallow poorly chewed food
associated with high blood alcohol levels and
dentures
Children

• Toys
• Balloons
• Small objects
• Food (hot dogs, nuts, candies, grapes)

Signs and Symptoms of Obstruction

• Partial Airway Obstruction

• Universal distress signal

• Good air exchange - forceful cough, may have wheezing

between coughs

• Poor air exchange - weak, ineffective cough, high-pitched

sounds, increased respiratory difficulty and possibly
cyanosis

• Complete Airway Obstruction

• Universal distress signal

• Unable to speak, breathe or cough

• Progresses to unconsciousness
 • Cyanosis

Management of Partial Airway Obstructed

• Good air exchange - encourage patient to continue coughing

until condition progresses to poor air exchange or complete
airway obstruction

• Poor air exchange - manage like complete airway obstruction

Management of Complete Airway Obstruction

(Refer to AHA's BLS Performance Sheets for the following)

Adult

• Conscious Adult

• Abdominal thrusts, repeat multiple times as necessary

• Unconscious Adult

• Attempt to ventilate, if unsuccessful, reposition head and

reattempt

• 5 abdominal thrusts

• Attempt to visualize foreign object and remove-blind

finger sweep permitted

• Attempt to ventilate

• Repeat entire sequence

Chest thrusts are recommended for patients in advanced

pregnancy or those who are markedly obese

Child
 • Conscious Child

• Abdominal thrusts, repeat multiple times as necessary

• Unconscious Child

• Attempt to ventilate, if unsuccessful, reposition head and

reattempt

• 5 abdominal thrusts

• Attempt to visualize foreign object and remove - NO blind

finger sweeps

• Attempt to ventilate

• Repeat entire sequence

Infant

• Conscious Infant

• 5 back blows and 5 chest thrusts, repeat series until

successful

• Unconscious Infant

• Attempt to ventilate, if unsuccessful reposition head and

reattempt

• 5 back blows and 5 chest thrusts

• Attempt to visualize foreign object and remove - NO blind

finger sweeps

• Attempts and reattempts to ventilate

• Repeat entire sequence until successful

Note: Managing FBAO for victims who are initially conscious and then

become unconscious follow a different sequence. Refer to skills sheet.

 AHA'S GUIDELINES FOR BLS

BREATHING

AGE VENTS/MIN DURATION

Adult 10-12/min 1-2 sec/breath

Child 20/min 1-1½ sec/breath

Infant 20/min 1-1½ sec/breath

CPR
Adult

Ratio 15:2 (One- and two- rescuer)

Rate 100/min

Depth 1½-2 inches to generate a palpable pulse

Hand Placement Hands on sternum between the nipple line

Child (1-8 years)

Ratio 5:1

Rate 100/min

Depth 1/3-1/2 depth of chest to generate a palpable

pulse

Hand Placement Heel of one hand over lower ½ of sternum

Infant (less than 1 year)

Ratio 5:1

Rate at least 100/min

Depth 1/3-1/2 depth of chest to generate a palpable

 pulse

Hand Placement 2 fingers one finger’s width below the nipple

line; or 2 thumbs encircling hands technique

RECOVERY POSITION

Roll patient laterally to prevent aspiration only if trauma not suspected

EMS ACTIVATION

Age

Over 8 years Activate EMS after assessing unresponsiveness

Up to 8 years Activate EMS after 1 min of CPR

Note: There are exceptions to this guideline.