___ American (elas Association BLS for Healthcare Providers Pee acs Y STE T|2. american Heart Associations BLS for Healthcare Providers STUDENT MANUAL Editor BLS Subcommittee 2010-2011 Mary Fran Hazinski, RN, MSN, Senior Science Eaitor Rober A, Berg, MD, Chair Diana M. Cave, RN, MSN, Immedtate Senior Managing Editor Pest Chair 2007-2009 . Lyn Hunter-Wilson Ben Bobrow, MO Carolyn L. Cason, RN, PRD Special Contributors Paul &. Chan, MD, MSo Janet Butle, MS, BLS HOP Writer Todd J. Crocco, MO Robin R. Hempnil, MO, MPH, Content Consultant Michael Cudnik, MD, MPH Robert A. Berg, MD Mohamud Daya, MD, MS Diana M. Cave, RN, MSN Dana P. Edelson, MD, MS Mare D. Berg, MD Berbara Furry, RNC, MS, CORN Diana D. Elmore, RN Raul J. Gazmuri, MD, PhO Michael R. Seyre, MD Theresa Hoadley, RN, PhO, TNS. Peter A. Meaney, MD, MPH Bizabeth A. Hunt, MD, MPH Louis Gonzales, BS, LP Vietor Johneon, EMT-P David Rogers, EdS, NREMT-P Mary Beth Mancini, RN, PhO Peter A. Meaney, MD, MPH James Newcome, NREMT-P Thomas D. Rea, MD, MPH Robert Swor, DO ‘Andrew H. Travore, MD, MSe ©2011 American Hear Assocation Brian Walsh, RAT 19BN 978--01069-090-7 Printed inthe Unites Stee of America Fist American Heart Association Printing March 2011 yi 191211 1098765432 @eBLS Subcommittee 2009-2010 Robert A. Berg, MD, Chair Diana M. Cave, RN, MSN, Immediate Past Chair, 2007-2008 ‘Benjamin Abela, MD, MPhil Tom P.Aufdetheide, MD Ben Bobrow, MD Fichard Branson, MS ‘Carolyn L. Cason, RN, PhO Paul S. Chan, MD, MSc Todd J. Crocco, MD. Michael Cudnik, MD, MPH Valerie J. De Maio, MD, MSe Ratll J. Gazmuri, MD, PhO ‘Anamed Idris, MD E. Brooke Lerner, PhO Peter A. Meaney, MD, MPH Vincent N, Mesesso, J, MD ‘Thomas D. Rea, MD, MPH Robert Swor, DO Andrew H. Travers, MD, MSc “Teresa Ann Volsko, RRT Pediatric Subcommittee 2010-2011 Mare D. Berg, MD, Chair Monica E. Kleinman, MD, Immediate Past Chair, 2007-2009 Dianne L. Atkins, MD Kathleen Brown, MD ‘Adam Cheng, MD Laura Conley, BS, ART, ROP, NPS ‘Alan . 6e Caen, MD ‘Aaron Donoghue, MD, MSCE Melinda L. Fiedor Harton, MD, MSe Ericka L. Fink, MD Eugene B. Freid, MD Cheryl K. Gooden, MD Sharon E, Mace, MD Bradey S. Marino, MD, MPP, MSCE Royion Meeks, RN, BSN, MS, MSN, EMT, PhD Jeffrey M. Periman, MB, ChB Lester Proctor, MD. Faiga A. Qureshi, MO Kesnith Hans Sartore, MD. Wendy Simon, MA Mark A. Torry, MPA, NREMT-P Alexis Topjian, MD Elise W. van der Jagt, MD, MPH Pediatric Subcommittee 2009-2010 Marc D. Berg, MD, Chair Monica E. Kleinman, MD, Immediate Past Chair, 2007-2009 Dianne L. Atkins, MO Jeffrey M. Berman, MD Kathieen Brown, MD ‘Adam Cheng, MD Laura Conley, BS, RAT, ACP, NPS Allan R. de Caen, MD ‘Aaron Donoghue, MD, MSCE Malinda L. Fiedor Hamilton, MD, MSe Ericka L. Fink, MD Eugene 8. Freid, MD Cheryl K. Gooden, MD John Gosford, 8S, EMT-P Patricia Howard Kelly Kadlec, MD Sharon E. Mace, MD Bradley S. Marino, MD, MPP, MSCE Reylon Meeks, RN, BSN, MS, MSN, EMT, PhD Vinay Nadkemni, MD Jeffrey M. Periman, MB, ChB Lester Proctor, MD Faiga A. Qureshi, MD Kennith Hans Sartoreli, MD Wendy Simon, MA Mark A. Terry, MPA, NREMT-P Alexis Topjian, MD Elise W. van der Jagt, MD, MPH Arno Zaritsky, MD To find out about any updates or corrections to this text, visit www.heart.org/cpr, navigate to the page for this course, and click on “Updates.”Part 1 General Concepts Part 2 BLS/CPR for Adults Introduction ‘The Purpose of This Manual The Chain of Survival Learning Objectives Introduction to the Adult Chain of Survival Introduction to the Pediatric Chain of Survival 2010 AHA Guidelines for CPR and ECC Science Update Overview Learning Objectives Change in Sequence: G-A-B, Not A-B-C Emphasis on High-Quality CPR No Look, Listen, and Feel Additional Changes: on ee eo NUKK BLS/CPR Basics for Adults Overview Learning Objectives Understanding the Basics of BLS ‘Overview of Initial BLS Steps Step 1: Assessment and Scene Safety Stop 2: Activate the Emergency Response System and Get an AED Step 3: Pulse Check ‘Step 4: Begin Cycles of 30 Chest Compressions and 2 Breaths (CPR) Ghest Compression Technique Mowing the Victim Only When Necessary Opening the Airway for Breaths: Head Tit-Chin Lift ‘Adult Mouth-to-Barrier Device Breathing Giving Adult Mouth-to-Mask Breaths Bag-Mask Device Using the Bag-Mask During 2-Rescuer CPR woeoorwvn|N RBRESRSASS2-Rescuer Adult BLS/Team CPR Sequence 15 Overview 16 Learning Objectives 15 When More Rescuers Arrive 15, Duties for Each Rescuer 16 2 Rescuers Using the Bag-Mask 16 Opening the Airway for Breaths: Jaw Thrust 7 rillator for Adults and Children 8 Years of Age and Older 19 Automated External Defibrillator for Adults and Children 8 Years of Age and Older 19 Overview 19 Learning Objectives. 19 AED Arrival 19 Special Situations 22 2-Rescuer BLS Sequence With an AED 24 2 Rescuers With an AED 24 1- and 2-Rescuer Adult BLS With AED Skills Testing Sheet 27 1- and 2-Rescuer Adult BLS with AED Skills Testing Criteria and Descriptors 2B Part 4 BLS/CPR for Children From 1 Year of Age to Puberty 29 BLS/CPR Basics for Children From 1 Year of Age to Puberty 29 Overview 29 Learning Objectives 29 Child BLS 29 Compression Rate and Ratio for Lone Rescuer 29 1-Handed Chest Gompressions 29 1 -Rescuer Child BLS Sequence 30 2-Rescuer Child BLS Sequence 31 Child Ventilation With Barrier Devices st Why Breaths Are Important for Infants and Children in Cardiac Arrest 31 _@Part 5 BLS/CPR for Infants 33 BLS/CPR Basics for Infants 33 Overview 33 Leaming Objectives 33 Infant BLS 3 Compression Depth in Infants 35 1-Rescuer Infant CPR 35 Compression Rate and Ratio for Lone Rescuer 35 1 -Rescuer Infant BLS Sequence 35 2-Finger Chest Compression Technique 26 Infant Ventilation With Barrier Devices 36 Why Breaths Are Important for Infants and Children in Cardiac Arrest 36 2-Rescuer Infant CPR 37 2 Thumb-Encircling Hands Chest Compression Technique ar 2-Rescuer Infant BLS Sequence 38 1- and 2-Rescuer Infant BLS Skills Testing Sheet 39 1- and 2-Rescuor Infant BLS Skills Testing Criteria and Descriptors 40 Part 6 Automated External Defibrillator for Infants and for Children From 1 to 8 Years of Age ai Automated External Defibrillator for Infants and for Children From 1 to 8 Years of Age 4 Overview 4 Learning Objectives 4a Choosing the AED Pads or AED Child System. 4a Use of an AED for Infants and Children a Use of an AED for Infants a4 Part 7 CPR With an Advanced Airway 43 CPR With an Advanced Airway 43 Overview 43 Compression Rate and Ratio During 2-Rescuer CPR With and Without an Advanced Airway in Place 43Part 8 Mouth-to-Mouth Breaths 45 Mouth-to-Mouth Breaths 45 Overview 45 Leaming Objectives 45 Adult Mouth-to-Mouth Breathing 45 Additional Techniques for Giving Breaths 46 Infant Mouth-to-Mouth-and-Nose and Mouth-to-Mouth Breathing 46 Part 9 Rescue Breathing 49 Adult, Child, and Infant Rescue Breathing 49 Overview 49 Rescue Breathing 49 Part 10 Relief of Choking 51 Relief of Choking in Victims 1 Year of Age and Older 5t Overview 51 Learning Objectives st Recognizing Choking in a Responsive Adult or Child 51 Relieving Choking in a Responsive Victim 1 Year of Age or Older 52 Relieving Choking in an Unresponsive Vietim 1 Year of Age or Older 53 Sequence of Actions Atter Relief of Choking 54 Relief of Choking in Infants 54 ‘Overview 54 Learning Objectives, 54 Recognizing Choking in a Responsive Infant 54 Relieving Choking in a Responsive Infant 55 Relieving Choking in an Unresponsive Infant 55 Appendix 57 Healthcare Provider Summary of Steps of CPR for Adults, Children, and Infants 57 Recommended Reading 59 4 oIntroduction General Concepts ‘Welcome to the BLS for Healthcare Providers Course. With the knowledge and skills you lear in this course, you can save a life. You will learn the skills of CPR for victims of all, ages and will practice CPR in a team setting. You will learn how to use an automated external defibrillator (AED) and how to relieve choking (foreign-body airway obstruction). ‘The skills you learn in this course vill enable you to recognize emergencies such as sud- den carsiac arrest and know how to respond to them. Despite important advances in prevention, cardiac arrest remains a substantial public health problem and a leading cause of death in many parts of the world. Cardiac arrest ‘cours both in and out of the hospital. In the United States and Canada, approximately 350000 peopie per year approximately half of them in-hospital) have a cardiac arrest and receive attempted resuscitation. This estimate does not include the substantial number of victims who have an arrest without attempted resuscitation, The Purpose of This Manual ‘This manual focuses on what healthcare providers need to know to perform CPR in a wide variety of in- and out-of-hospital settings. The manual details the information and skills you will leam in this class: Initiating the Chain of Survival Performing prompt, high-quality chest compressions for adult, child, and infant victims “+ Initiating early use of an AED Providing appropriate rescue breaths Practicing 2-rescuor team CPR, Relieving chokingere tat High-quality CPR improves a victim's chances of survival. The critical characteristics of high-quality OPR include * Start compressions within 10 seconds of recognition of cardiac arrest. Push hard, push fast: Compress at a rate of at least 100/min with a depth of at least 2 inches (6 em) for adults, approximately 2 inches (5 cm) for children, and approximately 1¥%6 inches (4 cm) for infants. + Allow complete chest recoil after each compression + Minimize interruptions in compressions (try to limit interruptions to <10 seconds). + Give effective breaths that make the chest rise Avoid excessive ventilation. The Chain of Survival Learning After reading this section you will be able to name the links in the American Heart Objectives Association (AHA) adult Chain of Survival and state the importance of each link. Introduction to The AHA has adopted, supported, and helped develop the concept of emergency the Adult Chain cardiovascular care (ECC) systems for many years. of Survival ‘The term Chain of Survival provides a useful metaphor for the elements of the ECC systems concept (Figure 1). The § links in the adult Chain of Survival are + Immediate recognition of cardiac arrest and activation of the emergency response system Early cardiopulmonary resuscitation (CPR) with an emphasis on chest compressions Rapid defibrillation Effective advanced life support Integrated post-cardiac arrest care Figure 4. The adult Chain of Survival. Although basic life support is taught as a sequence of distinct steps to enhanos skills retention and clarify priorities, several actions should be accomplished simultaneously (eg, begin CPR and activate the emergency response system) when multiple rescuers are present Introduction to Although in adults cardiac arrest is often sudden and results from a cardiac cause, in the Pediatric Chain children cardiac arrest is often secondary to respiratory failure and shock. Identifying chik of Survival Gren with these problems is essential to reduce the likelinood of pediatric cardiac arrest and maximize survival and recovery. Therefore, a prevention link is added in the pediatric Chain of Survival (Figure 2): < — 2+ Prevention of arost Early high-quality bystander CPR Rapid activation of the EMS (or other emergency response) system Effective advanced life support (including rapid stabilization and transport to definitive care and rehabilitation) Integrated post-cardiac arrest care Figure 2. The padiatic Chain of Survival 2010 AHA Guidelines for CPR and ECC Science Update Overview ‘The 2010 American Heart Association Guidelines for Carolopulmonary Resuscitation and Emergency Cardiovascular Care recommendations for healthcare providers include the following key changes and issues + Changes in basic life support (BLS) sequence ‘+ Continued emphasis on high-quality CPR, with minor changes in compression rate and dopth ‘= Additional changes regarding cricoid pressure, pulse check, and AED use in infants, Learning After reading this section you will be able to name the major science updates in the Objectives 2010 AHA Guidelines for CPR and ECC. Change in The 2010 AHA Guidelines for CPR and ECC recommend a change in the BLS sequence of Sequence: steps from A-B-C (Airway, Breathing, Chest compressions) to C-A-B (Chest compressions, C-A-B, Not A-B-C Airway, Breathing) for adults, children, and infants. This change in CPR sequence requires reeducation of everyone who has ever learned CPR, but the consensus of the authors and ‘experts involved in creating the 2070 AMA Guidelines for CPR and ECC is that the change is likely to improve survivalIn the A-B-C sequence, chest compressions were often delayed while the rescuer ‘opened the airway to give mouth-to-mouth breaths, retrieved a barrier device, or gathered and assembled ventilation equipment. By changing the sequence to C-A-B, rescuers can start chest compressions sooner, and the delay in giving breaths should be minimal (only the time required to deliver the first cycle of 30 chest compressions, or approximately 18 seconds or less; for 2-rescuer infant or child CPA, the delay will be even shorter). Emphasis on The 2010 AHA Guidelines for CPR and ECC once again emphasize the need for high- High-Quality CPR ‘quality CPR, including + A.compression rate of at least 100/min (this is a change from “approximately 00/min). + A.compression depth of at least 2 inches (5 cm) in adults and a compression depth 6f at least one third of the anterior-posterior diameter of the chest in infants and children. This is approximately 1% inches (4 cm) in infants and 2 inches (5 cm) in children: Note that the range of 1¥% to 2 inches is na longer used for adults, and the absolute depth specified for children and infents is deeper than in previous versions of the AMA Guidelines for CPR and ECC. + Allowing complete chest recoil, minimizing interruptions in compressions, and avoid- ing excessive ventilation continue to be important components of high-quality CPR To further strengthen the focus on high-quality CPR, the 2070 AHA Guidelines for CPR and ECC stress the importance of training using a team approach to CPR. The steps in the BLS Algorithm have traditionally been presented as a sequence to help a single rescuer prioritize actions, ‘There is increased focus on providing CPA as a team because resuscitations in most EMS and healthcare systems involve teams of rescuers, with rescuers performing several actions simultaneously. For example, one rescuer activates the emergency responsa system while a second begins chest compressions, a third is either providing ventilations or retrieving the bag-mask for rescue breathing, and a fourth is retrieving a defibrilator and preparing to use it. No Look, Listen, Another key change is the removal of “look, listen, and feel for breathing” from the and Feel ‘assessment stop. This step was removed because bystanders often failed to star CPR when they observed agonal gasping, The healtheare provider should nat delay activating the emergency response syatom but should check the victim for 2 things simultanoously responce and breathing, With the now chest compression-frst sequence, the rescuer should activate the emergency response system and begin CPR if the adult victim is une- sponsive and not breathing or not breathing normally (only gasping) and has no pulse. Fer the child or infant victim, CPR is portormed ifthe victim is unresponsive and not breathing cr only gasping and has no pulse. For victims of all ages (except newborns), begin CPR with compressions (C-A-B sequence). After each set of chest compressions, open the airway and give 2 breaths.Additional ‘There are several additional changes in the 2010 AHA Guidelines for CPR and ECC: Changes Co 5 ‘The routine use of oricoid Although cricoid pressure can prevent gastric infla~ pressure in cardiac arrest is | tion and reduce the risk of regurgitation and aspira- not recommended tion during bag-mask ventilation, it may also block ventilation, Several randomized studies have shown that cricoid pressure can delay or prevent the placement of {an advanced airway and that some aspiration can still occur despite the use of cricoid pressure. In adsition, its dificult to appropriately train rescuers ovr to do this. Therefore, the routine use of cricoid pressure in Cardiac arrest is not recommended. Continued de-omphasis of —_| It can be difficult to determine the presence or the pulse check absence of a puise within 10 seconds, especially in an emergency, and studies show that both health- care providers and lay rescuers are unable to reliably detect a pulse. Hf the victim is unresponsive and not breathing or only gasping, healthcare providers may take up to 10 seconds to attempt to feel for a pulse (brachial in an infant and carotid or femoral in a child), I within 10 seconds you don't fee! a pulse or are not sure if you feel a pulse, begin chest compressions. Use of an AED for infants For infants, a manual defibrillator is preferred to an AED for defibrillation. Ifa manual defibrillator is not available, an AED equipped with a pediatric dose attenuator is preferred. If neither is available, you may use an AED without a Pediatric dose attenuator. For more detailed information and references, read the 2010 AHA Guidelines for CPR and ECG, including the Executive Summary, published online in Girculation in October 2010, or the Highlights of the 2010 AHA Guidelines for CPR and ECO, available at ‘www:heart.org/eceguidelines. You can also roview the detailed summary of resuscita- tion science in the 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, published simultaneously in Circulation and ResuscitationBLS/CPR for Adults BLS/CPR Basics for Adults Overview This section describes the basic steps of CPR for adults. Adults include adolescents (ic, after the onset of puberty). Signs of puberty include chest or underarm hair in males and any breast development in females. Learning At the end of this section you will be able to Objectives ++ Tell the basic steps of CPR for adults, ‘+ Show the basic steps of CPR for adults Understanding BLS consists of these main parts the Basics of BLS (Figure 9): ‘Chest compressions = Airway + Breathing + Defibrillation You will learn about each of these throughout this course. Distinct from the lone responder approach, many workplaces and most EMS and in-hospital resusci- tations involve teams of providers: who should perform several actions simultaneously (eg, one rescuer activates the emergency response sysiem while a second rescuer begins chest compressions, a third is either providing ventitations or retrieving the bag-mask for rescue breathing, and a fourth is retrieving a defibrilator and prepar- ing to use i). This course focuses on team-based CPR. Figure 3. The Simpitiog adut BLS Algorithm for Healthcare Providers.Follow these initial BLS steps for adults: rer ‘Assess tho victim for a response and look for normal or abnorral brat ing. if there is no response and no breathing or no normal breathing (@ gasping), shout for help, If you are alone, activate the emergency response system and get an Af (or defibrillator) if available and return to the victim. ‘Check the victim's pulse (take at least 5 but no more than 10 seconds) Ifyou do not definitely feel a pulse within 10 seconds, perform & cyak compressions and breaths (30:2 ratio), starting with compressions sequence). Step 1: Assessment The first rescuer who arrives at the side of the victim must quickly be sur tat he and Scene Safety is safe. The rescuer should then check the victim for a response: Make sure the scene is safe for you and the victim. You do not want io become a victim yourselt. Tap the victim's shoulder and shout, “Are you all right?” (Figure 4), ‘Check to see if the victim is breathing. Ifa victim is not breathing or not breathing normally (le, only gasping), you must activate the emegendy response system. “Agonal gasps are net normal breathing. Agonal. gasps may be present inthe fst utes after sudden cardiac arrest. ‘A person who gasps usually looks like he is drawing air in very quickly. The mo be open and the jaw, head, or neck may move with gasps. Gasps may appea ft {ul or weak, and some time may pass between gasps because they usually a slow rate. The gasp may sound like a snort, snore, or groan. Gasping is not ns breathing. It isa sign of cardiac arrest in someone who doesn't respond. Ifa victim is not breathing or there is no normal breathing (le, only agonal gasps must activate the emergency response system, check the pulse, and start OP,Step 2: Activate the Emergency Response System and Get an AED Step 3: Pulse Check I you are alone and find an unresponsive victim not breathing, shout for help. if no one: responds, activate the emergency response system, get an AED (or defibrillator i avail- able, and then return to the victim to check a pulse and begin CPR (C-A-B sequence) Figure 4. Check for response and breathing and activate the emergency response systern (assess and ‘ectivate). A, Tap the victim's shoulder and shout, “Are you all ight?” At the same time look for breathing B, Ifthe adut victim dooe not reepend and has no breathing or ne normal breathing (, is only gasping), shout for help. another rescuse responds, sand him or hor to aotivato the emergancy responce system ‘and get the AED (or defbiato) f avatable. Ino one responds, activate the emergency response systom, Cet the AED (or defibilaton), and return to the victim to check a pulse and begin GPR (C-A-B sequence) Healthcare providers should take no more than 10 secondss to check for a pulse. Locating the Carotid Artery Pulse ‘To perform a pulse check in the adult, palpate a carotid pulse (Figure 5). If you do not efinitely feel a pulse within 10 seconds, start chast compressions. Follow these steps to locate the carotid artery pulse: Locate the trachea, using 2 or 3 fingers (Figure 5A), 4 2 | Slide these 2 or 3 fingers into the groove between the trachea and the mus- cles at the side of the neck, where you can feel the carotid pulse (Figure 5B). 3 | Feel for a pulse for at least 5 but no more than 10 seconds. If you do nat definitely feel a pulse, begin CPR, starting with chest compressions (C-A-B sequence). “ce Figure 5. Fincing tne carotid pulse. &, Locate the trachea. 8, Gently fo0I for tho carotid puse.Step 4: Begin The lone rescuer should use the compressian- ventilation ratio of 30 compressions to Cycles of 30 Chest 2 breaths when giving OPR to victims of any age. Compressions and When you give chest compressions, it is important to push the chest hard and fast, at 2 Breaths (CPR) ory e . B a rate of at least 100 compressions per minute, allow the chest to recoil completely after each compression, and minimize interruptions in compressions. Begin with chest compressions. Chest Compression The foundation of OPR is chest compressions. Follow these steps to perform chest com= Technique pressions in an adult: 1 _| Position yourself at the victim’s side. 2 | Make sure the victim is lying faceup on a firm, flat surface. If the victim is Iying facedown, carefully roll him faceup. If you suspect the victim has a heed or neck injury, try to Keep the head, neck, and torso in a line when rolling the victim to a faceup postion. 3 | Put the heel of one hand on the center ofthe victim’s chest on the lower half of the breastbone (Figure 6A). 4 | Put the heel of your other hand on top of the first hand. 8 _| Straighten your arms and position your shoulders directly over your hands. 6 | Push hard and fast. + Press down at least 2 inches (5 cm) with each compression (this requires hard work). For each chest compression, make sure you push straight down on the victim's breastbone (Figure 68). ‘+ Deliver compressions in a smooth fashion at a rate of at least 100/min, 7 | At the end of each compression, make sure you allow the chest to recoil (te-expand) completely. Chest recoil allows blood to flow into the heart and is necessary for chest compressions to create blood flow. Incomplete chest recoil is harmful because it reduces the blood flow created by chest com- pressions. Chest compression and chest recoil/relaxation times should be approximately equal Minimize interruptions.er i tae ake) esta cir a B Figure 6. A, Place your hands on the breastbone in the center ofthe chest. B, Correct positon of the rescuer during chest compressions. ‘Compressions pump the bioad in the heart to the rest of the body. ifa firm surface is under the vietim, the force you use will be more likely to compress the chest and heart and create blood flow rather than simply push the victim into the mattress or other soft surface. Ue ea ad PCR a URC Col Reason) If you have difficulty push- ing deeply during compres- sions, put one hand on the breastbone to push on the chest. Grasp the wrist of that hand with your other hand to ‘support the first hand as it pushes the chest (Figure 7). This technique is helpful for rescuers with arthritis. Figure 7. Alternate technique for chest compressions. Moving the Victim Only When Necessary Do not move the victim while CPR is in progress unless the victim is in a dangerous envi- ronment (such as a burning building) or i you believe you cannot perform CPR effectively in the victim's present position or location, CPR is better and has fewer interruptions when rescuers perform the resuscitation where they find the victim,Opening the Airway There are 2 methods for opening the ainway to provide breaths: head tit-chin ltt and jaw for Breaths: Head tvust. Two rescuors are generally neodad to perform a jaw thrust and provide breaths Tilt-Chin Lift with @ bag-mask device. This is discussed in the *2-Rescuer Adult BLS/Team CPR Sequence" section. Use a jaw thrust only if you suspect a head or neck injury, as it may reduce neck and spine movement. Switch to a head ti-chin lift maneuver if the jaw thrust does not open the airway. Follow these steps to perform a head tit-chin lft (Figure 8) 4 | Place one hand on the victim's forehead and push with your palm to tit the hhead back. 2 | Place the fingers of the other hand under the bony part ofthe lower jaw near the chin, 3 | Liftthe jaw to bring the chin torward. OX< , Ys (\ — | —— a 5 Figure 8. Tre head tit-chin It refeves away obstruction in an unresponsive vetim. A, Obstruction by the tongue. When 2 victin Is unresponsive, the tongue can block tha upper away. 8, The head tt-chin ft ‘maneuver its the tongue, ralleving airway obstruction. * Do not press deeply into the soft tissue under the chin because this might block the airway. * Do not use the thumb to lft the chin. = Do not clase the victim's mouth completely. Adult Mouth-to- Standard precautions include using barrier devices, such as a face mask (Figure 9) or a Barrier Device bag-mask device, when giving breaths. Rescuers should replace face shields with mouth- Breathing to-mask or bag-mask devices at the first opportunity. Masks usually have a 1-way valve that diverts exhaled air, blood, or bodily fluids away from the rescuer. Figure 9. Face maskene ae ea ere as ‘The risk of infection from CPR is extremely low and limited to a few case reports, but the US Occupational Safety and Health Administration (OSHA) requires that healthcare workers use standard precautions in the workplace, including during CPR. Giving Adult Mouth-to-Mask Breaths For mouth-to-mask breaths, you use a mask with or without a 1-way valve. The 1-way valve allows the rescuer’s breath to enter the victim’s mouth and nose and diverts the vic- tims exhaled air away from the rescuer. Some masks have an oxygen inlet that allows you to administer supplementary oxygen. Effective use of the mask barrier device requires instruction and supervised practice, Giving Mouth-to-Mask Breaths ‘To use a mask, the lone rescuer is at the victim's side. This position is ideal when perform- ing 1-rescuer CPR because you can give breaths and perform chest compressions when Positioned at the victim’s side. The lone rescuer holds the mask against the victim's face land opens the airway with @ head tift-chin litt. Follow these steps to open the airway with a head tilt-chin lift and use a mask to give breaths to the victim: 1__| Position yourself at the victim's side 2 | Place the mask on the victim's face, using the bridge of the nose as a guide for correct position. 3 | Seal the mask against the face: ‘= Using the hand that is closor to the top of the victim's head, place your index finger and thumb along the edge of the mask. «= Place the thumb of your second hand along the bottom edge of the mask. 4 | Place the remaining fingers of your second hand along the bony margin Of the jaw and lift the jaw. Perform a head tilt-chin lit to open the airway (Figure 10). 5 | While you litt the jaw, press firmly and completely around the outside edge of the mask to seal the mask against the face. 6 _| Deliver air over 1 second to make the victim's chest rise. Figure 10. Wouth-to-mask breaths, 1 rescuer. The rescuer performs t~escuer GPR trom a pasion ‘at tho victim's side, Perform a head tt-chin lit to open the airway wile holding the mask tightly ecaint the faceBag-Mask Device Bag-mask devices consist of a bag attached to a face mask. They may aiso include a t-way valve. Bag-mask devices are the most common method that healthoare providers use to give positive-pressure ventilation during GPR. The bag-mask ventiation technique. requires instruction and practice and is not recommended by a lone rescuer curing CPR. Using the Bag-Mask During 2-Rescuer cPR Follow these steps to open the airway with a head tit-chin lift and use a bag-mask to ghe | breaths to the victim: 1 | Position yourself directly above the victim’s head. 2 | Place the mask on the victim's face, using the bridge of the nose as a guide for correct position. 3 | Use the E-C clamp technique to hold the mask in place while you lft the jaw to hold the airway open (Figure 17}: * Perform a head tit * Place the mask on the face with the narrow portion at the bridge of the nose. * Use the thumb and index finger of one hand to make a of the mask, pressing the edges of the mask to the face. * Use the remaining fingers to lift the angles of the jaw (3 fingers form an ), open the airway, and press the face to the mask. ‘on the side 4 | Squeeze the bag to give breaths (1 second each) while watching for chest rise. Deliver all breaths aver 1 second whether or not you use supplementary oxygen, Figure 14. south-to-mask E-C clamp technique of holding mask while iting the jaw. Postion youll at tho vitim’s head, Place the thumb and fist finger ound the top of the mask forming a °C") whe using the thir, fourth, and fithfingere (forming an “E’) to It the jaw. eee nat ean tcc essa If you are using supplementary oxygen with a bag-mask device, you will stil dalver ‘each breath over 1 second. If you use only 1 second per breath for any method ot delivery, you can help minimize the interruptions in chest compressions needed for breaths and avoid excessive ventilation.2-Rescuer Adult BLS/Team CPR Sequence When More Rescuers Arrive This section explains how to perform 2-rescuer team CPR for adults [At the end of this section you will be able to show how to perform 2-rescuer team CPR, When a second rescuer is available to help, that second rescuer should activate the emer- gency response system and get the AED. The first rescuer should remain with the victim to start CPR immediately, beginning with chest compressions. After the second rescuer returns, the rescuers should use the AED as soon as itis available. The rescuers will hen give compressions and breaths but should switch roles after every 5 cycles of CPR (about every 2 minutes), ‘As additional rescuers arrive, they can help with the bag-mask ventilation, use of the AED or defibrillator, and crash cart Duties for Each Rescuer In 2-rescuer CPR (Figure 12), each rescuer has specific duties: Rescuer ed Rescuer 1 | At the victim's side |» Perform chest compressions. = Compress the chest at least 2 inches om. ~ Compress at a rate of at least 100/min. ~ Allow the chest to recoil completely after each compression. ~ Minimize interruptions in compressions (try to limit any interruptions in chest compressions to <10 seconds), — Use @ compressions-to-breaths ratio of 30:2. = Count compressions aloud. ‘Switch cuties with the second rescuer ‘every 5 cycles or about 2 minutes, taking <6 seconds to switch, Rescuer 2 | At the victim's head Maintain an open airway using either ~ Head tilt-chin lift = Jaw thrust Give breaths, watching for chest rise and avoiding excessive ventilation. Encourage the first rescuer to perform compressions that are deep enough and fast enough and to allow complete chest recoil between compressions. ‘Switch duties with the first rescuer, every 5 cycles or about 2 minutes, taking <6 seconds to switch.Figure 12. Two-rescier CPR. The frst rescuer poriorms chest compressions. ‘The second rescuer pertorms bag-mask ventilation using a mask with supplemen- tary oxygen (when availabe). The second rescuer ensures that the chest rsos with ‘each broath, Rescuora should switch roles after 5 cycles of CPR (about every 2 minutes). eee aE ie a Rad peau Nar ety Cored 2 Rescuers Using the Bag-Mask Effective teams communicate continuously. f the compressor counts out ioud, the res- cuer providing breaths can anticipate when breaths will be given and prepare to give them efficiently to minimize interruptions in compressions. The count will also help both rescuers to know when the time for a switch is approaching. Itis hard work to deliver effective chest compressions. if the compressor tires, chest ‘compressions won't be as effective. To reduce rescuer fatigue, switch compressor roles every 5 cycles (about 2 minutes). To minimize interruptions, perform the switch when the AED is analyzing the rhythm and take no more than 5 seconds to switch. When 8 or more rescuers are present, 2 rescuers can provide more effective bag-mask ventilation than 1 rescuer, When 2 rescuers use the bag-mask system, one rescuer opens the airway with a head tit-chin lift (or jaw thrust) and holds the mask to the face while the other resouer squeezes the bag (Figure 13). All professional rescuers should leam both the ++ and 2-resouer bag-mask ventilation techniques. When possible in the course, practice with devices for both bag-mask and mouth-to-mask ventilation. Figure 13. Two-rescuor bag-mask ventilation. The rescuer atthe victim's head tits the victim's head and seals the mask against the viet’ face with the thumo ang fist inger of each hand, creating a °C" to provide 2 cormplato ‘seal around the edges of the mask. The resouer usae the remaining 3 fingers {the “E") to lit tho jaw this holds tne airway open) and hold the face up against the mask. The second rescuer ‘slowly squeezse the bag (over 1 second) until the chest rises. Both rescuers should wateh for chest rise.Opening the Airway for Breaths: Jaw Thrust If the victim has a head or neck injury and you suspect 2 spine injury, 2 rescuers may use another method to open the airway: a jaw thrust (Figure 14). Two people perform a jaw thrust while holding the neck still and giving bag-mask ventilation. If the jaw thrust does not open the airway, use a head tit-chin lt. Figure 44. Jaw thrust without head ti. The Jaw i ited without titing the head. This is the ‘away maneuver of choice when the vietim has a possible spine nur. Follow these steps to perform a jaw thrust: Place one hand on each side of the victim's head, resting your elbows ton the surface on which the victim is lying. Place your fingers under the angles of the victim's lower jaw and lift with both hands, displacing the jaw forward (Figure 14). 3 If the lips close, push the lower lip with your thumb to open the fips.Automated External Defibrillator for Adults and Children 8 Years of Age and Older Automated External Defibrillator for Adults and Children 8 Years of Age and Older Overview ‘The interval from collapse to defibrillation is one of the most important determinants of survival from sudden cardiac arrest with ventricular fibrillation (see Foundational Facts, below) or pulseless ventricular tachycardia, Automated external dofibrilators (AEDs) are computerized devices that can identify cardiac rhythms that need a shock, and they can then deliver the shock. AEDs are simple to ‘operate, allowing laypersons and healthcare providers to attempt defibrillation safely. Learning At the end of this section you will be able to Objectives ‘+ List the steps common to the operation of all AEDs + Show proper placement of the AED pads ‘+ Recall when to press the SHOCK button when using an AED ‘+ Explain why no one should touch the victim when prompted by the AED during analysis and shock delivery ‘+ Describe the proper actions to take when the AED gives a “no shock indicated” (or “no shock advised") message + Show coordination of CPR and AED use to minimize = Interruptions in chest compressions = Time between last compression and shock delivery ~ Time between shock delivery and resumption of chest compressions AED Arrival (Once the AED arrives, place it at the victim's side, next to the rescuer who will operate it. This position provides ready access to the AED controls and easy placement of AED pads. It also allows a second rescuer to perform CPR from the opposite side of the victim without interfering with AED operation. Note: If multiple rescuers are present, one rescuer should continue chest compressions while another rescuer attaches the AED pads.@Q UE i tam When ventricular fibrillation is present, the heart muscle fibers quiver and do not con- tract together to pump blood. A defibrillator delivers an electric shock to stop the quiv- ering of the heart fibers. This allows the muscle fibers of the heart to “reset” so that they can begin to contract at the samo time. Once an organized rhythm occurs, the heart muscle may begin to contract effectively and begin to generate a pulse (called return of spontaneous circulation, or ROSC). eer a) AEDs are available in different models with a few differences from model to model, but all AEDs operate in basically the same way. There are 4 universal steps for operating an AED: Note: To reduce the time to shock delivery, you should ideally be able to perform the first 2 steps within 30 seconds after the AED arrives at the victim's side. POWER ON the AED (the AED will then guide you through the next steps). + Open the carrying case or the top of the AED, = Turn the power on (some devices will “power on” automatically when you open the lid or caso). 2 | ATTACH AED pads to the victim's bare chest. * Choose adult pads (not child pads or a child system) for victims 8 years of age and older. '* Peel the backing away from the AED pads. + Attach the adhesive AED pads to the victim's bare chest. ~ Place one AED pad on the victim's upper-right chest (directly below the collarbone). ~ Place the other pad to the side of the left nipple, with the top edge of the pad a few inches below the armpit (Figure 18). ‘Attach the AED connecting cables to the AED box (some are preconrecied 3 | “Clear” the victim and ANALYZE the rhythm. + If the AED prompts you, clear the victim during analysis. Be sure no one is touching the victim, not even the rescuer in charge of giving breaths. ‘+ Some AEDs will tel you to push a button to allow the AED to begin ana- lyzing the heart rhythm; others will do that automatically. The AED may take about 5 to 15 seconds to analyze, + The AED then tells you ia shock is needed, 4 | Ifthe AED advises a shock, it will tell you to clear the vietim. ‘+ Clear the victim betore delivering the shock: be sure no one is touching the victim, + Loudly state a “clear the victim” message, such as “Everybody olear* or simply *Clear.” * Look to be sure no one is in contact with the victim. Press the SHOCK button + The shock will produce a sudden contraction of the victim's muscles. & | If no shock is needed, and after any shock delivery, immediately resume CPR, starting with chest compressions. 6 After 5 cycles or about 2 minutes of CPR, the AED will prompt you to repaat steps 3 and 4 If Sno shock advised,” immediately restart CPR beginning with chest compressions.Figure 15. 4&0 pad placement on the vctn Analysis of thousands of rhythm strips recorded before and after shock delivery has ‘shown that if rescuers can keep the time between the last compression and shock delivery to 10 seconds or less, the shock is much more likely to be effective (ie, to oliminate ventricular fibrillation and result in return of spontaneous circulation). PCr ee od Tae aK CTS Cees eee Sede Effectiveness of shock delivery decreases significantly for every adcitional 10 seconds that elapses betwesn last compression and shock delivery. Minimizing this interval will require practice and excellent team coordination, particularly between the compressor and the rescuer operating the defibrillator. You may leave an AED attached while transporting the victim on a stretcher or in ‘an ambulance. Never push the ANALYZE button while moving the victim. Because movement can interfere with rhythm analysis and artifacts can simulate ventricular fibrillation, the rescuer must bring the stretcher or vehicle to a complete stop and then reanalyzeSpecial Situations ‘The following special situations may require the rescuer to take additional actions when using an AED: ‘= The vietim has a hairy chest. ‘= The victim is immersed in water or water is covering the victim's chest. + The vietim has an implanted defibrilator or pacemaker. ‘The victim has a transdermal medication patch or other object on the surface of the skin where the AED pads are placed. Hairy Chest If a teen or adult victim has a lot of chest hair, the AED pads may not properly stick to the skin on the chest. If this occurs, the AED will not be able to analyze the victim’s heart rhythm, The AED will then give a “check electrodes” or “check electrode pads” message. od re 1 | Ifthe pads stick to the hair instead of the skin, press down firmly on each pad, 2 | If the AED continues to prompt you to “check pads” or “check electrodes,” quickly pull off the pads. This will remove a large amount of hair and should allow the pads to stick to the skin, 3 | tra targe amount of hair stil remains whore you will put the pads, shave the area with the razor in the AED carrying case. Put on a new set of pads. Follow the AED voice prompts. Water Water is a good conductor of electricity. Do not use an AED in water If the victim is in water, pull the victim out of the water. If the victim is lying in water or the chest is covered. with water, the water may conduct the shock electricity across the skin of the victim's chest. This prevents the delivery of an adequate shock dose to the heart. If water is cover= ing the victim's chest, quickly wipe the chest before attaching the AED pads. If the victim is lying on snow or in a small puddle, you may use the AED. implanted Defibrillators and Pacemakers Victims with a high risk for sudden cardiac arrest may have implanted defibrilators/pace- makers that automatically deliver shocks directly to the heart, You can immediately iden- tify these devicas because they create a hard lump beneath the skin of the upper chest or abdomen. The lump is half the size of a deck of cards, with an overiying scar. If you place ‘an AED pad directly over an implanted medical device, the device may block delivery of the shock to the heart.lf you identify an implanted defibrilator/pacemaker: * If possible, avoid placing the AED pad directly over the implanted device. * Follow the normal steps for operating an AED. ‘Occasionally the analysis and shook cycies of implanted defibrillators and AEDs will con- flict. if the implanted defibrilator is delivering shocks to the victim (the victim's muscles Contract in a manner like that observed after an AED shock), allow 30 to 60 seconds for ‘the implanted defibrillator to complete the treatment cycle before delivering a shock from the AED. Transdermal Do not place AED pads directly on top of a medication patch (eg, a patch of nitroglycerin, Medication nicotine, pain medication, hormone replacement therapy, or antihypertensive medication). Patches ‘The medication patch may block the transfer of energy from the AED pad to the heart and ‘may cause small burns to the skin, If it won't delay shack delivery, remove the patch and wipe the area clean before attaching the AED pad.2-Rescuer BLS Sequence With an AED 2 Rescuers Follow these BLS steps for 2 rescuers with an AED: With an AED 4 | Check for response and check breathing: If the victim does not respond and is not breathing or not breathing normally (ie, only gasping): + The first rescuer stays with the victim and performs the next steps until the second rescuer returns with the AED. “= The second rescuer activates the emergency response system and gets the AED. 2 | Check for pulse: If a pulse is not definitely felt in 10 seconds: ‘+ The first rescuer removes or moves clothing covering the victim's chest (thie will alow rescuers to apply the AED pads when the AED arrives). * The first rescuer starts CPR, beginning with chest compressions. 3 Attempt defibrillation with the AED: ‘= When the AED arrives, place it at the victim's side near the rescuer who will be operating it. The AED is usually placed on the side of the victim ‘opposite the rescuer who Is performing chest compressions (Figure 18), 4 | POWER ON the AED (the AED will then guide you through the next steps) igure 17). + Open the carrying case or the top of the AED. ‘+ Turn the power on (some devices will “power on” automatically when you open the lid or case). 5 | ATTACH AED pads to the victim's bare chest (Figure 18). * Choose adult pads (not child pads or a child system) for victims 8 years of age and older. * Peel the backing away from the AED pads. * Attach the adhesive AED pads to the victim's bare chest. = Place one AED pad on the victim's upper-right chest (directly below the collarbone). = Place the other pad to the side of the left nipple, with the top edge of the pad a few inches below the armpit (Figure 15). ‘Attach the AED connecting cables to the AED box (some are precon- nected), 6 | “Clear” the victim and ANALYZE the rhythm (Figure 19), ‘= If the AED prompts you, clear the victim during analysis. Be sure no one is touching the victim, not even the rescuer in charge of gwving breaths. * Some AEDs will tel you to push a button to allow the AED to begin ana- lyzing the heart rhythm; others will do that automatically. The AED may take about 5 to 15 seconds to analyze. ‘+ The AED then tells you if @ shock is needes. (continued)(continued) If the AED advises a shock, it will tell you to clear the victim. | * Clear the victim before delivering the shock (Figure 20A): be sure no one is touching the victim Loudly state 2 “clear the victim” message, such as “Everybody clear” or simply “Clear.” * Look to be sure no one is in contact with the victim. * Press the SHOCK button (Figure 208) + The shock will produce a sudden contraction of the vietim’s muscles. Ifno shock is neaded, and after any shock delivery, immediately resume CPR, starting with chest compressions (Figure 21). After 5 cycles or about 2 minutes of GPR, the AED will prompt you to repeat steps 6 and 7 IF ‘no shock advised,” immediately restart CPR beginning with chest compressions.reas A ‘oe figure 17. AED operator tums AED on, Figure 18. Rescuar attaches AED pacs tothe victim and then altaches Figure 19. The AED operator cloars tho vitim before the electrodes to the AED. ‘mythm analySs. i needed, the AED operator then activates the ANALYZE feature ofthe AED, \-4 : 5 oe nee Q — |BLS for Healthcare Providers Course 9. ‘American 1- and 2-Rescuer Adult BLS With AED @ Heart ciation: Skills Testing Sheet See 1- and 2-Rascuer Adult BLS With AED Skills Testing Criteria and Descriptors on next page ‘Student Name: Test Date | CPR Skills (circle oni Pass Needs Remediation AED Skills (circle one) Pass Needs Remediation E Bod 1-Rescuer Adult BLS Skills Evaluation During this first phase, evaluate the first rescuer's abilty to initiate BLS and deliver high-quality CPR for 5 cycles. 1 | ASSESSES: Checks for response and for no breathing or no normal breathing, only gasping {at least 5 seconds but no more than 10 seconds) 2 _| ACTIVATES emergency response system '3_| Checks for PULSE (no more than 10 seconds) ‘4 | GIVES HIGH-QUALITY CPR: aie) '* Correct compression HAND PLACEMENT ‘+ ADEQUATE RATE: At least 100/min (e, delivers each set of 30 chest compressions in 118 seconds or less) if done CeCe coe Hi Kselid Ti: + ADEQUATE DEPTH: Delivers compressions at least 2 inches in depth (at least 23 out of 30) | eles: + ALLOWS COMPLETE CHEST RECOIL (at least 23 out of 30) Cyclo 4: + MINIMIZES INTERRUPTIONS: Gives 2 breaths with pocket mask in less than 10 seconds | Gyele S: ‘Second Rescuer AED Skills Evaluation and SWITCH During this next phase, evaluate the second rescuers ability to use the AED and both rescuers’ abilities to switch roles. DURING FIFTH SET OF COMPRESSIONS: Second rescuer arrives with AED and bag-mask | device, tums on AED, and applies pads First rescuer continues compressions while second rescuer turns on AED and applies pads ‘Second rescuer clears victim, allowing AED to analyre—RESCUERS SWITCH IFAED indicates a shockable rhythm, second rescuer clears victin again and delivers shock Rescuer Bag-Mask Ventilation this next phase, evaluate the frst rescuer's abilty to give breathe with a bag-mask. Both rescuers RESUME HIGH-QUALITY GPA immediately afier shock delivery One | Cycle + SECOND RESCUER gives 30 compressions immediately after shock delivery (for 2 cycles) | Z].|.|.] » “i + FIRST RESCUER succassfully delivers 2 breaths with bag-mask for 2 cycles) AFTER 2 CYCLES, STOP THE EVALUATION + Ifthe student completes all steps successfully (a ¥ in each box to the right of Critical Performance Criteria), the student passed this scenario, * Ifthe student does not complete all steps successfully (as Indicated by a blank box to the right of any of the Critical Portormance Criteria), give the form to the student for review as part of the student's remediation, * Alter reviewing the form, the student will give the form to the instructor viho is reevaluating the student. The student will ‘eperform the entire scenario, and the instructor will notate the reevaluation on this same form. + ifthe reevaluation is to be done at a cfferent time, the instructor should collect this sheet before the student leaves the classroom. Remediation (i needed): Instructor Signature: Instructor Signature: Pint instructor Name: Date: Date: Print Instructor Name:BLS for Healthcare Providers Course 1- and 2-Rescuer Adult BLS With AED Skills Testing Criteria and Descriptors 58 Assesses victim (Steps 1 and 2, assessment and activation, must be completed within 10 seconds of arrival at scene}: + Checks for unresponsiveness (this MUST precede starting compressions) ‘= Checks for no breathing or no normal breathing (only gasping) . Activates emergency response system (Steps 1 and 2, assessment and activation, must be completed within 10 seconds of arrival at scene): ‘= Shouts for help/directs someone to call for help AND get AED/defiorilator Checks for pulse: * Checks carotid pulse * This should take no more than 10 seconds Delivers high-quality CPR (initiates compressions within 10 seconds of * Correct placement of hands/fingers in center of chest ~ Adult: Lower half of breastbone ~ Adult: 2-nanded (second hand on top of the first or orasping the wrist of the first hand) ‘= Compression rate of at least 100/min = Delivers 30 compressions in 18 seconds or less + Adequate depth for age ‘+ Adult: at least 2 inches (6 om) ‘+ Complete chest recall after each compression ‘+ Minimizes interruptions in compressions: ~ Less than 10 seconds between last compression of one cycle and first compression of next cycle = Compressions not interrupted until AED analyzing rhythm = Compressions resumed immediately after shock/no shock indicated Integrates prompt and propor use of AED with CPR: = Tums AED on ‘= Places proper-sized pads for victim's age in correct location Clears rescuers from victim for AED to analyze rhythm (pushes ANALYZE button if required by device) Clears victim and delivers shock. Resumes chest compressions immediately after shock delivery Does NOT turn off AED during CPR Provides safe environment for rescuers during AED shock delivery: ~ Communicates clearly to all other rescuers to stop touching victim = Delivers shock to victim after all rescuers are clear of victim ‘+ Switches during analysis phase of AED Provides effective breaths: * Opens airway adequately * Delivers each breath over 1 second * Delivers breaths that produce visible chest rise * Avoids excessive ventilationBLS/CPR for Children From 1 Year of Age to Puberty BLS/CPR Basics for Children From 1 Year of Age to Puberty Overview in females. Learning Objectives This section covers the basic steps of CPR for children from 1 year of age to puberty, Signs of puberty include chest or underarm hair on males and any breast development {At the end of this section you will be able to tell the basic steps of CPR for children. Child BLS Compression Rate and Ratio for Lone Rescuer 1-Handed Chest Compressions The child BLS sequence and skills are similar to the sequence for adult BLS. The key ifferences between child and adult BLS are + Compression-ventilation ratio for 2-rescuer CPR: 15:2 ratio for 2-rescuer child CPR ‘+ Compression depth: For children, compress at least one third the depth of the chest, approximately 2 inches (5 cm) ‘= Compression technique: May use 1- or 2-handed chest compressions for very small children ‘+ When to activate the emergency response system: ~ If you did not witness the arrest and are alone, provide 2 minutes of CPR before leaving the child to activate the emergency response system and get the AED (or defibrillator). = Ifthe arrest is sudden and witnessed, leave the child to activate the emergency response system and get the AED (or defibrillator), and then return to the chil. The lone rescuer should use the universal compression-ventilation ratio of 30 compres- sions to 2 breaths when giving CPR to victims of all ages (except newly born infants). The term universal represents a consistent recommended ratio for all lone rescuers for victims. of all ages. For very small children you may use either 1 or 2 hands for chest compressions. Make sure you compress the chest one third the depth of the chest with each compression,Many infants and children are thought to develop respiratory arrest and bradycardia before they develop cardiac arrest. if such children receive prompt CPR betore devel- ‘opment of cardiac arrest, they have a high survival rate. ea ce DRTC Picasa ue Secu If the rescuer leaves a child with respiratory arrest or bradycardia to phone the emer- gency response system, the child may progress to cardiac arrest, and the chance of survival will be much lower. For this reason, if the lone rescuer finds an unresponsive child who is not breathing or only gasping, the rescuer should provide 5 cycles (about 2 minutes) of OPR before activating the emergeny response system. Recommended depth of compressions: = Adults: AT LEAST 2 inches * Children: At least one third of the anterior posterior depth of the chest or APPROXIMATELY 2 inches (6 om) ee ee Maen) 4-Rescuer Child Follow these steps to perform the 1-rescuer BLS sequence for a chil SES Seeccnee aga 4 | Check the child for a response and check breathing. If there is no response and no breathing or only gasping, shout for help, 2 | if someone responds, send that person to activate the emergency response system and got the AED. Note: If the child collapsed suddenly and you are alone, leave the child to activate the emergency response system and get the AED; then return to the child, 3 | Check the child's pulse (take at least 5 but no more than 10 seconds). You may try to feel the child's carotic or femoral pulse. 4 | if within 10 seconds you con't defintely feel a pulse or if, despite adequate ‘oxygenation and ventilation, the heart rate is <60/min with signs of poor perfusion, perform cycles of compressions and breaths (80:2 ratio), starting with compressions, & | After 5 cycles, if someone nas not already done so, activate the emergency response system and get the AED (or defibrilaton. Use the AED as coon as itis available. Locating the To perform a pulse check in tho child, palpate a carotid or femoral pulse. If you do not Femoral Artery definitely feel a puise within 10 seconds, start chest compressions, Pulse Follow these steps to locate the femoral artery puls=: Stop ee 1 | Place 2 fingers in the inner thigh, midway between the hipbone and the pubic bone and just below the crease where the leg meets the abdomen. 2 | Feel for a pulse for at east 5 but no more than 10 seconds. If you do not definitely feel a pulse, begin GPR, starting with chest compressions (C-A-B sequence).2-Rescuer Child Follow these steps to perform the 2-rescuer BLS sequence for a child (no AED}: BLS Sequence 1 | Check the child for a response and check breathing, If there is no response and no breathing or only gasping, the second rescuer activates the emer. gency response system 2 | Check the child's pulse (take at least § but no more than 10 seconds). You may try to feel the child’s carotid or femoral pulse. 3_| Ifwithin 10 seconds you don’t definitely feel a pulse or if, despite adequate ‘oxygenation and ventilation, the heart rate is <60/min with signs of poor perfusion, perform cycles of compressions and breaths (30:2 ratio). When the second rescuer arrives, use a comprassions-to-breaths ratio of 18: Child Ventilation Use barrier devices in the same manner as for adults. Wil: Rerrtor To prove bagask verti, select aba ar mask of appropriates. The mask ‘must be able to cover the victim's mouth ang nose completely without covering the eyes or overlapping the chin, Once you select the bag and mask, perfor ahead tit-cin it to open the vietin’s arway. Pre tho mask tothe child's face as you It the child’ ew, making a seal between the clos face and the mask. Connect supplementary oxygen to the mask when available Why Breaths When sudden cardiac arrest oocurs (i, typical cari arrestin an adult, the oxygen Are important content of the blood is typically normal, 0 compressions alone may maintain adequate for Infants and oxygen delivery to the heart and brain for the first few minutes after arrest. eens In contrast, infants and children who develop cardiac arrest often have respiratory failure ‘or shock that reduces the oxygen content in the blood even before the onset of arrest. AS « result, for most infants and children in cardiac arrest, chest compressions alone are not 28 ettective for delivering oxygen to the heart and brain as the combination of compres- sions plus breaths. For this reason, it is very important to give both compressions and breaths for infants and children during CPR. ny High-quality CPR improves a victim's chances of survival. The critical characteristics of high-quality CPR in adults include * Start compressions within 10 seconds of recognition of cardiac arrest, + Push hard, push fast: Compress at a rate of at least 100/min with a depth of at least 2 inches (5 cm) for adults, approximately 2 inches (6 cm) for children, and approximately 1% inches (4 cm) for infants. + Allow complete chest recoil after each compression. ‘= Minimize interruptions in compressions (try to limit interruptions to <10 seconds) * Give effective breaths that make the chest rise. * Avoid excessive ventilation.BLS/CPR for Infants BLS/CPR Basics for Infants Overview This section covers the basic steps of CPR for infants. Learning ‘At the end of this section you will be able to Objectives * Tell the basic steps of CPR for infants + Show the basic steps of CPR for infants Infant BLS For the purposes of the BLS sequence described in the Pediatric BLS Algorithm (Figure 22), the term infant means infants to 1 year of age (12 months), excluding nevrly born infants in the delivery room, For BLS for children 1 year and older, see “BLS/CPR for Children From 1 Year of Age to Puberty.” The infant BLS sequence and skils are very similar to those used for child and adut CPR The key differences for infant BLS are + The location of pulse check: brachial artery in infants, + Technique of delivering compressions: 2 fingers for single rescuer and 2 thumb-eneitcling hands technique for 2 rescuers. ‘+ Compression depth: at least one third the chest depth, approximately 1% inches (4 em) ‘+ Compression-ventilation rate and ratio for 2 rescuers: same as for child —15:2 ratio for 2 rescuers + When to activate the emergency response system (same as for chil — If you aid not witness the arrest and are alone, provide 2 minutes of CPR before leaving the infant to activate the emergency response system and get the AED (0° defibrilaton. = = Ifthe arrest is sudden and witnessed, leave the infant to phone 911 and get the AED (or defibrilator), then return to the infant.Qa Unresponsive Not breathing or only cesping ‘Sond someone to activato emergency Fesponse system, get AED/defbrilator High-Quality CPR ‘= Rate atleast 100/min + Compression epih to atleast Ys anterior posterior ‘tamater of chest, ‘bout 1% niches (em) in intents ‘and 2 inches (S em) Inchicron ‘Allow complete ‘chest recol ator each compression ‘= Minenze itomruptions In chest compressions ‘Avoid excossie ventilation ‘After about 2 minutos, activate emergency response system and get AED/defibillator (if not already done). Use AED as soon as available. Give 1 shock Resume CPR immediately or 2 minutes ‘Note: The boxes bordored with dashed nes are performed by healthoore providere and not by lay escuore Figure 22. the Pedavic 61 Algoihn. Locating the To perform a pulse check in an infant, palpate a brachial pulse. It can be difficult for Brachial Artery healthcare providers to determine the prosence or absence of a pulse in any victim, but it Pulse can be particularly difficult in an infant |f an infant is unresponsive and not breathing or only gassing and you do not definitely {feel a pulse within 10 seconds, start CPR. It is important that you begin chest compres- sions if you do not definitely fool a pulse within 10 seconds.Follow these steps to locate the brachial artery pulse: 4 | Place 2 or 3 fingers on the inside of the upper arm, between the infant's | stoow and shoulder 2 | Press the index and middle fingers gently on the inside of the upper arm tor at least 5 but no more than 10 seconds when attempting to feel the pulse | (Figure 23), Figure 23. Paipation ofthe cente ‘an infant; finding the brachial artery. pulse in Compression In infants, the recommended compression depth is at least one third of the anterior-pos- Depth in Infants terior depth of the infant's chest, or approximately 1% inches (4 cml. This is different from ‘compression depth for both adults (at least 2 inches) and children (at least one third the depth of the chest, anproximately 2 inches [5 om). -4-Rescuer Infant CPR Compression “The lone rescuer should use the universal compression-ventilation ratio of 30 compres- Rate and Ratio sions to 2 breaths when giving CPR to victims of all ages. The term universal represents for Lone Rescuer an attempt to develop @ consistent ratio for lone rescuers. 4-Rescuer Infant Follow these steps to perform 1-rescuer BLS for an infant: : BLS Sequence | 4 | Check the infant for a response and check breathing. If there is no response {and no breathing or only gasping, shout for help, 2 | it someone responds, send that person to activate the emergency response system and get the AED (or defibrillator). 3 | Check the infant's brachial pulse (lake at least 5 but no more than 10 seconds), 4 | itthere is no pulse or if, despite adequste oxygenation and ventilation, the heart rate is <60/min with signs of poor perfusion, perform cycles of com- pressions and breaths (30:2 ratio), starting with compressions. | 5 _| After § cycles, if someone has not already done so, activate the emergency response system and get the AED (or defibrillator).2-Finger Chest Compression Technique Infant Ventilation With Barrier Devices Follow these steps to give chest compressions to an infant using the 2-finger technique: Step 2 | Place 2 fingers in the center of the intant’s chest just below the nipple line. Do not press on the bottom of the breastbone (Figure 24), 3 | Push hard and fast. To give chest compressions, press the infant's breast- bone down at least one third the depth of the chest (approximately 17 inches [4 cm). Deliver compressions in a smooth fashion at a rato of at loast 100/min, 4 | At the end of each compression, make sure you allow the chest to recoil ((eexpand) completely. Chest recoil allows blood to flow into the heart and is Necessary to create blood flow during chest compressions. Incomplete chest recoil will reduce the blood flow created by chest compressions, Chast com- pression and chest recoil/laxation times should be approximately equal 5 __| Minimize interruptions in chest compressions. Figure 24. two-tinger chest compression tecrnque in infant. Use barrier devices in the same manner as for adults. To provide bag-mask ventilation, select a bag and mask of appropriate size. The mask ‘must be able to cover the infant's mouth and nose completely without covering the eyes 6 overlapping the chin. Once you select the bag and mask, perform a head titchin lift to open the victim's airvray. Press the mask to the infant's face as you lft the infant's jaw, ‘making a seal between the infant's face and the mask. Connect supplementary oxygen to the mask when available. For more information on techniques for giving breaths, refer to the “Infant Mouth-to-Mouth- and-Nose and Mouth-to-Mouth Breathing” section in Part 6. Why Breaths Are Important for Infants and Children in Cardiac Arrest When sudden cardiac arest occurs (le, typical cardiac arrest in an adult), the oxygen con- tent of the blood is typically normal, so compressions alone may maintain adequate oxy- gen delivery to the heart and brain for the first few minutes after arrest. In contrast, infants and children who develop cardiae arrest often have respiretory failure ‘or shock that reduces the oxygen content in the blood even before the onset of arrast. As a result, for most infants and children in cardiac arrest, chest compressions alone are not as effective for delivering oxygen to the heart and brain as the combination of compres- sions plus breaths. For this reason, it is very important to give both compressions and breaths for infants and children during GPR.If you tit (extend) an infant's head beyond the neutral (sniffing) position, the infant's, airway may become blacked. Maximize airway patency by positioning the infant with the neok in a neuttal position so that the external ear canal is level with the top of the Infant's shoulder. -Rescuer Infant CPR 2 Thumb- Encircling Hands Chest Compression Technique The 2 thumb-encircling hands technique is the preferred 2-rescuer chest compression technique for healthcare providers who can fit their hands around the infant's chest. This technique produces blood flow by compressing the chest with both the thumbs. The 2 thumb-encircling hands technique produces better blood flow, more consistently results in ‘appropriate depth or force of compression, and may generate higher blood pressures than the 2-fingar technique. Follow these stens to give chest compressions to an infant using the 2 thumb-encircling hands technique: 1 | Place both thumbs side by side in the center of the infant's chest on the lower haif of the breastbone. The thumbs may overlap in very small infants. 2 | Encircle the infant's chest and support the infant's back with the fingers of oth hands. 3 | With your hands encircling the chest, use both thumbs to depress the breastbone approximately one third the depth ofthe infant's chest (approx mately 1¥ inches [a em) (Figure 25). 4 _| Deliver compressions in a smooth fashion at a rate of at least 100/min. 5 | After each compression, completely release the pressure on the breastbone and allow the chest to recoil completely 6 | After every 15 compressions, pause briefly for the second rescuer to open. the airway with a head tit-chin lift and give 2 breaths. The chast should rise with each breath. 7 | Continue compressions and breaths in a ratio of 15:2 (for 2 rescuers), switching roles every 2 minutes to avoid rescuer fatigue. igure 25. two tumd-enctriing hands technique for infant @ rescuer)2-Rescuer Infant Follow these steps for 2-rescuer BLS for infants: BS seucre aa aaa 1 | Check the victim for a response and for breathing. 2 | Ifthere is no response and no breathing or only gasping, send the second rescuer to activate the emergency response system and get the AED (or defibxilator) . 3 | Check the infant's brachial pulse (take at least § but no more than 10 seconds} 4 | if there is no pulse or if, despite adequate oxygenation and ventilation, the heart rate (pulse) is <60/min with signs of poor perfusion, perform cycles of ‘compressions and breaths (30:2 ratio), starting with compressions. When the ‘second rescuer artives and can perform CPR, use a compression-ventiation ratio of 19:2. 5 _| Use the AED (or defibrillator) as soon as itis available.BLS for Healthcare Providers Course American 1- and 2-Rescuer Infant BLS here 4 ssociation. Skills Testing Sheet See 1- and 2-Rescuer Infant BLS Skills Testing Criteria and Descriptors on next pago Student Name: __ Test Date: - 4-Rescuer BLS and CPR Skills (circle one}: Pass Needs Remediation 2-Rescuer CPR Skills Bag-Mask (circle one}: Pass Needs Remediation 2 Thumb-Eneireling Hands (circle one): Pass, Needs Remedi eT done = Cee Coa aot Rescuer Infant BLS Skills Evaluat During this first phase, evaluate the first rescuers ability to initiate BLS and deliver high-quality CPR for 5 cycles. ‘ASSESSES: Checks for response and for no breathing or only gasping (at least 5 seconds but ‘no more than 10 seconds) ‘Sends Someone to ACTIVATE emergency response system ‘Chesks tor PULSE [no more than 10 seconds) *+ Gorrect compression FINGER PLACEMENT Oye 1: . irae BATE: Atleast 100/min (e, delvar each et of 30 chest comprossions in Gye2_| Tine 18 seconds or less) | + ADEQUATE DEPTH: Delivers compressions at least one third the depth of the chest Opies: approximately 1% inches [4 cm) (at east 23 out of 30) | ALLOWS COMPLETE CHEST RECOIL (at least 2 | + MINIMIZES INTERRUPTIONS: Gives 2 breaths with pockei mask in less than 10 seconds | Oye 5: 2-Rescuer GPR and SWITCH During this nent phase, evaluate the FIRST RESCUER’S abilty to give breathe with a bag-mask and give compressions by 2 thumb-encircling hands technique. Also evaluate bath rescuers’ abilities to switch roles, 5 _ | DURING FIFTH SET OF COMPRESSIONS: Second rescuer arrives with bag-mask device. RESCUERS SWITCH ROLES. 6 | Both rescuers RESUME HIGH-QUALITY CPR: ‘* SECOND RESCUER gives 15 compressions in 9 seconds or less by using 2 thumt encircling hands technique (for 2 cycles) + FIRST RESCUER successfully delivers 2 breathe with bag-mask (for 2 cycles) ____ AFTER 2 CYCLES, PROMPT RESCUERS TO SWITCH ROLES: 7 | Both rescuers RESUME HIGH-QUALITY CPR: Opie | Cyee? * FIRST RESCUER gives 18 compressions in 9 seconds or less by using 2 thumb-oncirciing | Time: Tine: hands technique (for 2 cycles) [= SECOND RESCUER successuly delivers 2 breathe with bag-mask (or2 oyces aaa I AFTER 2 CYCLES, STOP THE EVALUATION Ifthe student completes all stepe euccesstully (a ¥ in each box to tha right of Crit passed this scenario. * Ir the student does not complete all steps successfully (as indicated by a blank box to the right of any of the Critical Performance Criteria), give the form to the student for review as part of the student's remediation, * Aiter reviewing the form, the student will give the form to the instructor wha is reevaluating the student. The student will reperform the entire scenario, and the instructor will notate the reevaluation on this same form, + Ih the reevaluation is to be done at a sitferent time, the instructor should collect this sheet before the student leaves the classroom, Remediation {if needed): alls] sa Performance Criteria) the student Instructor Signature: Instructor Signature: - Print instructor Name: Print Instructor Name: —_ Date: Date: = ee i ee QaBLS for Healthcare Providers Course 1- and 2-Rescuer Infant BLS Skills Testing Criteria and Descriptors 1. Assesses victim (Steps 1 and 2, assessment and activation, must be completed within 10 seconds of arrival at scene): ‘+ Checks for unresponsiveness (this MUST precede starting compressions) = Checks for no breathing or only gasy 2. Sends someone to activate emergency response system (Steps 1 and 2, assessment and activation, must be completed within 10 seconds of arrival at scene): + Shouts for help/directs someone to call for help AND get AED/defibrilator * falone, remains with infant to provide 2 minutes of CPR before activating emergency response system 3. Checks for pulse: * Checks brachial pulse ‘+ This should take no more than 10 seconds 4. Delivers high-quality 1-rescuer CPR [initiates compressions within 10 seconds of identifying cardiac arrest): * Correct placement of hands/fingers in center of chest ~ 1 rescuer: 2 fingers just below the nipple line ‘Compression rate of at least 100/min = Dalivers 30 compressions in 18 seconds or less ‘+ Adequate depth for age = Infant: at least one third the depth of the chest (approximately 1% inches [4 m)) Complete chest recoil after each compression ‘= Appropriate ratio for age and number of rescuers ~ 1 rescuer: 30 compressions to 2 breaths ‘+ Minimizes interruptions in compressions: = Less than 10 seconds between last compression of one cycle and first compression of next cycle 5, Switches at appropriate intervals as prompted by the instructor (for purposes of this evaluation) 6. Provides effective breaths with bag-mask device during 2-rescuer CPR: + Provides effective breaths: = Opens airway adequately Delivers each breath over 1 second = Delivers breaths that produce visible chest rise ~ Avoids excessive ventilation 7. Provides high-quality chest compressions during 2-rescuer CPR: + Correct placement of hands/fingers in center of chest = 2 rescuers: 2 thumb-encircling hands just below the nipple line Compression rate of at least 100/min ~ Delivers 15 compressions in 9 seconds or less Adequate depth for age Infant: at least on third the depth of the chest (epproximately 17 inches [4 cm) * Complete chest recoil after each compression + Appropriate ratio for age and number of rescuers = 2 rescuers: 15 compressions to 2 breaths, ‘+ Minimizes interruptions in compressions: Less than 10 seconds between last compression of one cycle and first compression of next cycleAutomated External Defibrillator for Infants and for Children From 1 to 8 Years of Age Automated External Defibrillator for Infants and for Children From 1 to 8 Years of Age ‘There are a few special considerations when using an AED on an infant or child from 1 to 8 years of age. At the end of this section you will be able to * Choose the correct size AED pads for an infant or child younger than 8 years of age + Tell when to attach and use an AED on an infant or child younger than 8 years of age ‘Some AEDs have been modified to deliver different shock doses: one shock dose for {adults and one for children. if you use a pediatric-capable AED, there are features that allow it to deliver a child-appropriate shock. The method used to choose the shack cose for a child citfers based on the type of AED you are using. your AED includes a smaller size pad designed for children, use it, If not, use the stan- ard pads, making sure they do not touch or overlap, The Important thing is to be familiar with the AED you will be using, if possible, before you Reed fo use it. When you are using an AED, remember to turn it on first and follow the Prompts as it leads you through the rest of the steps. As in adults, use the AED as soon as it is available. Use child pads and a child system, if available, for infants and for children less than 8 years of age. For infants, a manual defibrillator is preferred to an AED for defibrillation. If a manual defibrillator is not available, an AED equipped with a pediatric dose attenuator is preferred, If neither is available, you may use an AED without a pediatric dose attenuator,PREECE ET you 2re using an AED for an infant or for a child younger than 8 years of age and the | ‘AED does not have child pads or a child key or switch, you may use the adult pads land deliver the adult dose, Place the pads so that they do not touch each othor. Cee Pema ee rag ete) ed Deen Ce CEL Rat is Cea ye © Use the AED as soon as itis available. | * Uso the AED as soon as it is available. * Use only adutt pads (Figure 26).(Do | * Use child pads (Figure 27) if available. NOT use child pads or a child key or H you do not nave child pads, you may child switch for victims 8 years of age | use adult pads. Place the pads so that and older) they do not touch each other. + Ifthe AED has a key or switch that will | Geliver a child shook dose, turn the key or switch mh : me, AS eS | Figure 26. Aduit pod package. Figure 27. chi ped pockageCPR With an Advanced Airway CPR With an Advanced Airway Overview ‘This section explains how to do CPR with an advanced airway. Compression Rate and Ratio During 2-Rescuer CPR With and Without an Advanced Airway in Place The compression rate for 2-rescuer CPR is at least 100/min. Until an advancad airway (eg, laryngeal mask airway, supragiottic, or endotracheal tube) is in place, rescuers must pause compressions to provide breaths. The following table compares the combination of compressions and ventiiations with and, without an advanced airway. Ventilation Compressions to Breaths Compressions to Breaths red (Adult) (Child and Infant) No advanced —_| + 30 compressions to *+ 15 compressions to airway 2 breaths 2 breaths (mouth-to-mouth, | + Compression rate of at + Compression rate of at mouth-to-mask, | least 100/min least 100/min bbag-mask) ‘Advanced airway | © Compression rate of at least 100/min without pauses (endotracheal for broaths intubation, laryn- | * 1 breath every 6 to 8 seconds (6 to 10 breaths per minute) geal mask airway, supragiottic) ‘When an advanced airway is in place during 2-rescuer CPR, do not stop compressions. to give breaths. Give 1 breath every 6 to 8 seconds (8 to 10 breaths per minute), without attempting to deliver breaths between compressions, There should be no pause in chest compressions for delivery of breaths.Mouth-to-Mouth Breaths Mouth-to-Mouth Breaths Overview Because many cardiac arrests happen at home, you may need to give breaths to a family member or close friend when you are not working. This section shows how to give mouth- to-mouth breaths wien you do not have a pocket mask or bag-mask Learning Objectives At the end of this section you will be able to show how to give mouth-to-mouth breaths. Adult Mouth- to-Mouth Breathing Mouth-to-mouth breathing is a quick, effective way to provide oxygen to the victim, The rescuer's exhaled air contains approximately 179 oxygen and 4% carbon dioxide. This is. enough oxygen to meet the victim's needs. Follow these steps to give mouth-to-mouth breaths to the victim: Hold the victim's airway open with a head titt-chin lf. 2 | Pinch the nose closed with your thumb and index finger (using the hand on the forehead). 3 | Take a regular (not deep) breath and seal your lips around the victim's mouth, creating an airtight seal (Figure 26). 4 | Give 1 breath (blow for about 1 second). Watch for the chest to rise as you ive the breath. If the chest does not rise, repeat the head tlt-chin lift Give a second breath (blow for about 1 second). Watch for the chest to rise. If you are unable to ventilate the victim after 2 attempts, promptly return 10 chest compressions.Figure 28, Mouth-to-mouth breath. Additional Techniques for Giving Breaths If you give breaths too quickly or with too much force, air is rather than the lungs. This can cause gasttic inflation coy to entor the stomach Gastric inflation frequently develops during mouth-to-mouth, mouth-to-mask, or bag-mask ventilation. Gastric inflation can result in serious complications, such as vvorriting, aspiration, or pneumonia. Rescuers can reduce the risk of gastric inflation by avoiding giving breaths too rapidly, too forcefully, or with too much volume. During CPR, however, gastric inflation may develop even when rescuers give breaths correctly. ‘To raduee the risk of gastric inflation: * Take 1 second to deliver each breath, * Deliver air until you make the victim’s chest rise. Infant Mouth- to-Mouth-and- Nose and orn Mouth-to-Mouth eed Breathing Mouth-to-mouth-and- © Maintain a head tit-chin lift to keep the airway nose (preferred method) open. * Place your mouth over the infant's mouth and nose to create an airtight seal (Figure 29), * Blow into the infant’s nose and mouth (pausing to inhale betwoon breaths} to make the chest rise with ‘each breath, If the chest doos not rise, repeat the head tit-chin lift to reopen the airway and try to give a broath that makes the chest rise. It may be necessary to move the infant's head through a range of postions to provide optimal airway patency and effective rescue breaths. When the airway is open, give 2 breaths that make the chest rise. You may need to try a couple of times, (continued)(continued) Ce i) Ce Mouth-to-mouth (use this, method if you can't cover the nose and mouth with your mouth) PCLT Maintain a head tit-chin lift to keep the airway open, Pinch the victim's nose tightly with thumb and fore- finger. Make a mouth-to-mouth seal. Provide 2 mouth-to-mouth breaths. Make sure the chest rises with each breath, It the chest does not rise, repeat the head tit-chin lift to reopen the airway. It may be necessary to move the infant's head through a range of positions to provide optimal airway patency and effective rescue breaths. When the airway is open, give 2 breaths that make the chest rise. Figure 29. Moutn-to-mouth-and-nose breaths for an infant victimRescue Breathing Adult, Child, and Infant Rescue Breathing Overview This section tells how to do rescue breathing for adult, child, and infant viotims. Rescue When an adult, child, or infant has a pulse but is not breathing effectively, rescuers should Breathing sive breaths without chest compressions. Ths is rescue breathing. ‘The following table shows guidelines for rescue breathing for adults, children, and infants: Rescue Breathing for Inf: id De a ene Cry = i ie * Give 1 breath every 5 to 6 seconds * Give 1 breath every 3 to 5 seconds (about 10 to 12 breaths por minute). about 12 to 20 breaths per minute) * Give each breath in 1 second, + Each breath should result in visible chest rise. * Check the pulse about every 2 minutes. Note: In infants and children, if, despite adequate oxygenation and ventilation, the pulse is <<60/min with signs of poor perfusion, start CPR, TLC tre ml Respiratory arrest is the absence of respirations (ie, apnea). During both respiratory arrest and inadequate ventilation, the victim has cardiac output (bioad flow to the body) detectable as a palpable central pulse. The heart rate may be slow, and cardiac arrest may develop if rescue breathing is not provided. Oar ise Cs Healthcare providers should be able to identity respiratory arrest. When respirations are absent or inadequate, the healthcare provider must immediately ‘open the airway and give breaths to prevent cardiac arrest and hypoxic injury to the brain and other organs.10 Relief of Choking Relief of Choking in Victims 1 Year of Age and Older Overview This section covers common causes of choking and actions to relieve choking (foreign- body airway obstruction) in adults and children 1 year of age and older. Learning ‘At the end of this section you will be able to show how to relieve choking in responsive Objectives and unresponsive victims 1 year of age and older. Recognizing Early recognition of airway obstruction is the key to successful outcome. It is important Choking in a to distinguish this emergency from fainting, stroke, heart attack, seizure, drug overdose, Responsive or other conditions that may cause sudden respiratory distress but require different treat- Adult or Child ment. The trained observer can often dotect signe of choking. Foreign bodies may cause a range of symptoms from mild to severe airway obstruction. Lene eae due head Sign: ‘+ Good alr exchange ‘+ Can cough forcetully + May wheeze between coughs Signs: * Poor or no air exchange Weak, ineffective cough or no cough at all High-pitched noise while inhaling (oF no noise at all * Increased respiratory difficuty Possible cyanosis (turning biue) Unable to speak ‘+ Clutching the neck with the thum land fingers, making the universal ‘choking sign (Figure 30) eae eared ‘Ask the victim if he or she is choking. If the victim nods yes and cannot talk, severe airway ‘obstruction is present and you must try to relieve the obstruction ‘As long as good air exchange continues, encourage the victim to continue sponta- neous coughing and breathing efforts. Do not interfere with the victim's own attempts to expel the foreign body, but stay with the victim and moniter his or her condition. + If mild airway obstruction persists, acti- vate the emergency response system,Relieving Choking in a Responsive Victim 1 Year of Age or Older Abdominal Thrusts With Victim Standing or Sitting ‘The public should use the universal choking sign to indicate the need for help when choking (Figure 30). Figure 30. Usiversal choking sion. Use abdominal thrusts (the Heimiich maneuver) to relieve choking in a responsive victim 1 year of age or older. Do not use abdominal thrusts to relieve choking in infants. Give each indivicual thrust with the intent of relieving the obstruction. It may be necessary to repeat the thrust several times to clear the airway. Follow these steps to perform abdominal thrusts on a responsive adult or child who is standing or sitting: 1 | Stand or kneel behind the victim and wrap your arms around the victim's waist (Figure 31). 2 | Make a fist with one hand. 3 | Place the thumb side of your fist against the victim's abdomen, in the midline, slightly above the navel and well below the breastbone. 4 | Grasp your fist with your other hand and press your fist into the victim's abdomen with a quick, forceful upward thrust. 5 | Repeat thrusts until the object is expelled from the airway or the victim becomes unresponsive, 6 | Give each new thrust with a separate, distinct movement to relieve the obstruction,Figure 34. abdominal trrcte (Hoimich maneuver) with vietim stending. If the victim is pregnant or obese, perform chest thrusts instead of abdominal thrusts. Relieving Choking Choking victims initially may be responsive and then may become unresponsive. in this in an Unresponsive circumstance you know that choking caused the victim's symptoms, and you know 10 Victim 1 Year of look for a foreign object in the throat. Age or Older Ia choking victim becomes unresponsive, activate the emergency responce system. Lower the victim to the ground and begin CPR, starting with compressions (do not check for a pulse), For an adult or child victim, every time you open the airway to give breaths, open the vie- tim’s mouth wide and look for the object. If you see an object that can easily be removed, remove it with your fingers. If you do not see an object, Keep doing CPR. After about § cycles or 2 minutes of CPR, activate the emergency response system if someone has not already done so. ‘Sometimes the choking victim may be unresponsive when you first encounter him or her. In this circumstance you probably will not know that an airway obstruction exists. Activate the emergency response system and start CPR (C-A-B sequence).Relief of Choking Sequence of Actions After ‘You can tell you have successfully removed an alrway obstruction in an unresponsive victim if you! * Feel air movement and see the chest rise when you give breaths + See and remove a foreign body from the victim's mouth ‘After you relieve choking in an unresponsive victim, treat him or her as you would any unresponsive victim (ie, check response, breathing, and pulse), and provide CPR or res- cue breathing as needed. If the victim responds, encourage the victim to seek immediate ‘medical attention to ensure that the victim does not have a complication from abdominal thrusts. Relief of Choking in Infants Overview This section covers the steps to relieve choking (foreign-body airway obstruction) in an infant. For information on relieving choking in a child 1 year of age and older, see “Relist of Choking in Victims 1 Year of Age and Older” Learning At the end of this section you will be able to show how to relieve choking in responsive Objectives and unresponsive infants. Recognizing Early recognition of airway obstruction is the key to successful outcome. The trained Choking in a observer can often detect signs of choking. Responsive Infant Foreign bodies may cause a range of symptoms from mild to severe airway obstruction. Cire ac Signs: Good air exchange + Can cough forcefully + May wheeze between coughs erodes Recta ce Signs: Poor or no air exchange ‘+ Weak, ineffective cough or no cough at all + High-pitched noise while inhaling or no noise at all * Increased respiratory difficulty Possible cyanosis (turning blue) Unable to cry eee err Do not interfere with the infant's own attempts to expel the foreign body, but stay with the victim and monitor his or her condition, * if mild airway obstruction persists, activate the emergency response system, Ifthe infant cannot make any sounds or breathe, severe airway obstruction is present and you must try to relieve the obstruction.Relieving Clearing an object from an infant's airway requires a combination of back slaps and chest Choking in a thrusts. Abdominal thrusts are not appropriate Responsive Follow these steps to relieve choking in a responsive intant: Infant z = ds 1 | Knee! of sit with the infant in your lap. 2._| If itis easy to do, remove clothing from the infant's chest 3 | Hola the intant facedown with the head slightly lower than the chest, rest- ing on your forearm. Support the infant's head and jaw with your hand. Take care to avoid compressing the soft tissues of the infants throat. Rest your forearm on your lap or thigh to support the infant. 4 | Deliver up to § back slaps (Figure 32A) forcefully between the infant's shou! der blades, using the heel of your hand. Deliver each slap with sufficient force to attempt to dislodge the foreign body. 8 _| After delivering up to 5 back slaps, place your free hand on the infant's back, supporting the back of the infant's head with the palm of your hand. The infant will be adequately cradled between your 2 forearms, with the palm of ‘one hand supporting the face and jaw while the palm of the other hand sup- rts the back of the infant's head. ‘Turn the infant as a unit while carefully supporting the head and neck. Hold the infant faceup, with your forearm resting on your thigh. Keep the infant's, head lower than the trunk. 7 | Provide up to 5 quick downward chest thrusts (Figure 328) in the middle of the chest over the lower half of the breastbone (same as for chest comores: sions during CPR). Deliver chest thrusts at a rate of about 1 per second, each with the intention of creating enough force to dislodge the foreign body. 8 _ | Repeat the sequence of up to 5 back slaps and up to 5 chest thrusts until tho object is removed or the infant becomes unresponsive, A Figure 32. Rois of choking in an infant. A, Back slaps, B, Chest thrusts, Relieving De not pom bd tngr sweep infant and ren bac sweeps may ps he Choking in an foreign body back into the airway, causing further obstruction or injury. Hiarenpoceive Ite fant votim becomes unresponsive, sop giving bck sla nd bag OP‘To relieve choking in an unresponsive infant, perform the following steps: 1 | Call for help. if someone responds, send that person to activate the emer gency response system. Place the infant on a firm, flat surface. 2 | Begin CPR (starting with compressions) with 1 extra step: each time you ‘open the airway, look for the obstructing object in the back of the throat. If you see an object and can easily remove it, remove it, 3 | After approximately 2 minutes of CPR (C-A-B sequence), activate the emer- gency response system {if no one has done so).Healthcare Provider Summary of Steps of CPR for Adults, Children, and Infants Cer cad Adults Coos eed Recognition Unresponsive (for all ages) No breathing or no normal broathing No breathing or only gasping (ie, only gasping) No pulse felt within 10 seconds. CPR sequence Chest compress| Compression rate At least 100/min At loast AP diameter About 1 inches (4 om) ‘At least % AP diameter ‘At least 2 inches (5 cr) ‘Abotk ches GON Allow complete recoil between compressions jotate compressors every 2 minutes 2 Minimize interuptions in chest compressions, Attempt to limit interruptions to <10 seconds. | (until advanced airway placed) toh lift (euepected trauma: jaw thrust) 30:2 Bae Single rescuer 1 or2 rescuers 452 2 rescuers Ventilations with advanced airway 1 breath every 6-8 seconds (8-10 breaths/min) ‘Asynchronous with chest compressions About 1 second per breath Visible chest rise ‘Attach and use AED as soon as available. Minimize interruptions in chest compressions before and after shock; resume GPR beginning with compressions immediately after each shock. Abbreviations: AED, automated extemal defibrillator; AP, anterior posterior, CPR, cardiopulmonary resuscitation,Recommended Reading Recommended Reading 2010 Handbook of Emergency Cardiovascular Cara for Healticare Providers. Dallas, TK: ‘American Heart Association; 2010, Flaid JM, Hazinski MF, Sayre M, et al Part 1: executive surnmary: 2010 American Heart Association Guidelines for Carciopulmonary Rasuscttation and Emergency Cardiovascular Care. Circulation. -2010;122(6upp! 3):$640-S656. Hazinski MF, Nolan JP, Bil JE, eta, Part 1: executive summary: 2010 International Consensus ‘on Cardiopulmonary Resuscitation and Emergency Carciovascular Care Science With Treatment Recommendations. Circulation. 2010;122(supp! 2):S250-S275. Highights of the 2010 American Heart Association Guidelines for Cardiopulmonary Resusctation ‘and Emorgoncy Cardiovascular Care. Dallas, TX: American Heart Association; 2010. _werwheart orgieccquiselines.For your BLS renewal training, try these online course: To advance and specialize your tra Additional Training Options From the American Heart Association Congratulations on completing basic life support (BLS) training—an important part of your hhealtheare career. To advance your emergency cardiovascular care knowledge and skills, the American Heart Association has also developed these courses. In BLS for Healthcare Providers Online Part 1, students work through case-based scenarios and get feedback as they move through critical checkpoints, HeartCode® BLS Part 1 uses eSimulation technology so students “virtually treat” sudden cardiac arrest patients and follow interactive, simulated cases for feedback and debriefing. Part 1 of each course requires 1 to 2 hours to complete, plus additional time for a hands-on skills session. To learn more or purchase these courses, contact your training center o visit OnlincAHA.org. ig, consider these courses: irway Management allows students to lear, practice, and demonstrate many airway skills used in resuscitation and to increase their awareness of various airway products. EGG & Pharmacology addresses the electrocardiogram (ECG) an pharmacology, and focuses on specific ECG rhythm recognition skills and drug treatment knowledge. Pediatric Emergency Assessment, Recognition, and Stabilization (PEARS®) equips students to recognize and begin stabilization of victims before arrest. Students learn pediatric distress signs and symptoms with the use of unique visual cues and tools. The course includes work at learning stations and simulation to see and hear critically il chikirenOnline Advanced Cardiovascular Life Support (ACLS) builds on the foundation of BLS and the importance of high-quality CPR, This advanced course emphasizes effective teamwork, post-cardiac arrest care and integrated systems of care, The course is available as classroom-based or eLearning, Pediatric Advanced Life Support (PALS) uses a scenario-based, team approach to teach emergency management and treatment of pediatric respiratory and cardiac anest. The course is available as classroom-based or eLearning, ‘To learn more or purchase these courses, contact your training center or visit www.Hearorg/opr. Learn:™ Rhythm Adult introduces students to normal cardiac rhythms and prepares them to recognize basic cardiac arrhythmias. Students focus on improving ECG rhythm recognition. Learn:™ Rhythm Pediatric introduces normal pediatric cardiac chythms and prepares students to recognize basic pediatric cardiac arrhythmias in clinical practice. The course Includes interactive activitios and solf-assessments. ‘Three stroke courses are available for high-level training on the symptoms, identitication diagnosis, management, and treatment of various types of stroke. The online courses offer self-paced, interactive lessons. + Acute Stroke Online + Stroke Hospital-Based Care Online + Stroke Prehospital Care Online To learn more or purchase online courses, contact your training center or visit OnlineAHA.org. Healthcare Programs From the American Heart Association ‘The American Heart Association has created a variety of programs and produets for the public, healthcare professionals, and legislators that educate and raise awareness about ‘cardiovascular health and disease prevention. Many also provide tools and information to help individuals and groups make an impact on improving survival in their communities. Learn more and get involved today. Mission: Lifeline? Maran iat meinem mel AAS ICY Zhaly of ae for ST segment vation myocardial : cae Lan nowawmasearagnenoneine. LIFELINE), Get With The Guidelines” TMs ete of aulty-rnprovementproguts ‘empowers hospital teams to deliver heart and GET WITH THE stroke care consistent with the most up-to-date scientific guidelines. To learn more, visit GUIDELINES. www.Heartorg/GetWithTheGuidelines.CHANNING BETE COMPANY One Community Place | South Deerfield, MA 01373-0200 « PN eee ene) Ter eer ea) LAERDAL MEDICAL CORPORATION 167 Myers Corners Road | Wappingers Falls, NY 12590-8840 Pot el eae cre} Peer) WORLDPOINT ECC, INC cara PHONE: 888-322-8350 | FAX: 888-261-2627 Rey ere ences For more information on attier American ee ts re me Ute aa] RNA Leslee fers Ae iy lTaa me Ceara UN) =I 25 Coane © 200 ree or inl 16116905971