Download Study Guide - Redlands Community Hospital

American Heart Association (AHA) released updated guidelines for Cardiopulmonary
Resuscitation (CPR) in 2010. We are providing this study guide to assist you in leaming
the recommended procedures and skills. It is expected that you will review the
information shown in the current manual and practice your performance skills before you
come to class. During the class you will be required to:
,/
,/
written exam with a score of 84% or better
Demonstrate your hands-on CPR skills
Pass the
Your preparation for class will help assure your successful completion of the course.
If you have any questions please feel free to call extension 5530.
The American Heart Association strongly promotes knowledge and proficiency in CPR
and has developed instmctional material for this purpose. Use of these materials in an
educational course does not represent course sponsorship by the American Heart
Association, and any fees charged for such a course do not represent income to the
association.
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CPR
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BLS
for Healthcare Providers Student Manaal
Comparison Sheet
Based on 2010 AHA Guidelines for CPR and ECC
GUI
rS
BLS Changes
old
New
CPR
Chcst compressions, Airway, Br eathing
Airway, Breathing, Chcst compr.cssions
(A-B-C)
(c-A-B)
Ncw science indrcatcs the fbllorving ordcr:
l. Chcck llte pclcnl for rcsponsivencss
and no breathing.
2. Call for help and get the AED
3. Checl( thc pulse.
,1. Give 30 comprcssions.
5. Opcn the airway and give 2 breaths.
6. Rcsumecontpressions.
Compressions should bc initiatcd within
seconds olrccog:tition of the arrcst.
l0
Prcvior.tsly, a ftcr responsiverress was
-rssc.scd. r e:,ll tor hclp uas rnadc, rh<
auway rvas opelcd, the paticnt was checked
lor breathing, a;rd 2 breaths rvcre grven,
"ollouLd by., p.riqc cltucl ar,d cumplcssrorr:..
Comprcssions wcrc to be gi\er aftcr arrway
and brcathing wcrc assesscd, ventilatiolts
were given, and pulses werc checkcd.
Compressious should be given at a rate ofat
lca.t 100 milr. F:rch sct of .t0 cornpfe<srons
shoLLld take approximatcly l8 seconds or 1css.
Complessions wcrc to be givcn at a r.atc of
dbout I 00/min. Each cyclc of 30
cornpresslons was to be completed in 23
Compression dcpths arc as follorvs:
. Adulls: at lcast 2 inchcs (5 crn)
r Clhildrclr: at lcast onc thir.d the dcpth
Conrprcssion dcpths wcrc as follows:
. Adults. l% 1o 2 inches
r Chrldrun: one third ro onc halfthe
dtalneter-ofthe chcst
. Infalts: one third to onc half rne
Rationale
Although \'cntilations are an ilnportant pafl
of rcsuscitation, cvrdence shows that
conrprcssiun5 rrc lhc crrtrcal clcntL r rn
adult rcsuscitation. In thc A-B C scqucnct:,
comprcssions arc often delayed By
changing thc sequence to C-A-B, rcscuers
can slan chest comprcsslols sooller..
Although vcnlilations arc an jDtportant part
of resuscrtation, evidencc sllows that
comptesslons are thc crrtical .lcrncrl rn
adult resuscitatiotl. Comprcsstons are oticn
deiayed while providcrs open thc airwuy
and deliver brcaths.
Faster comprcssions ar'c rcquired to
gcneratc thc pressurcs nccessary to perfuse
thl] coronary and cerebral arler-jcs.
seconds or less.
oflhe cl)est. apptoxim:ltcly 2 tnchcs
.
@ 2010
(5 cm)
Infal]ts: at least one thi:.d the depth
ofthc chest, approximately I%
mches (4 cm)
dla:'Jrctcr
Decper- compressions are requircd 1o
generatc thc pressurcs nccessary to pcrl'use
the coronary and cerebral arterics.
of the chest
Amelican Heart Association. BLS HCP Intenm Materials. Use lor AI-IA BLS HCP Courscs untrl 201I BLS HCp materrals
are
released.
Airway
and
Breathing
AED Use
(-ricoid pressure rs no longer routrnell
recommcndcd 1br use with ventilatiolls.
lf
an adequate rrumber ofrcscucrs u,as
available, onc could apply cricoid pressure.
"Look, listcn, and feel lbr brcathing" has been
removed fiom tLc sequence for assessment of
breathiDg after opening the airway. Healthcarc
providers briefly chcck for brcathing when
chccking responsivcncss to detect signs of
cardjac arrest. After dclivery of30
compressions, lonc rcscuers opcn the vlctjm's
airway and delivcf 2 bleaths-
"Look, listen. and feel for breathing" was
For clrildren from I to 8 years ofage, an AED
a pediatric dose-attcnuator systcnt should
be uscd if available. lf an AED wirh a dosc
attenuator is not available, a standard AED
may be used.
This does not reprcsent a change {br
children. ln 2005 therc was not sufficient
evidence to recommeld for or against thc use
with
(<l year ofagc), a manuai
defibrillator is prefened. Ifa manr.Lal
defibrillator is not available, an AED rvrrn a
pediatric dose attcnuator is desirable. If
ncither is availablc, an AED without a dose
For infants
atten uator may be uscd.
uscd to assess brcathlng aftcr the airway was
opcncd.
Randomized studies have dcmonstratcd that
cricoid pressure still allows for aspiration. lt
is also difficult to properly train providers to
per-fbrm the maneuver corrcctly.
With thc new chest compression-first
sequencc, CPR is performcd rf the adult
victim is unresponsivc and not breatlting or
not brealhrng normall) {ie. nor brerrlrrrrg c'r
only gacping) cnd bcgins u rrh comprcsslons
(C-A-B sequcncct. Therelorc. brealhlng ls
brielly checked as part ofa check for
ol an AED in infants-
cardiac arrest. After the first set ofchest
compressions, thc airway is opened and the
rescuer dclivers 2 breaths.
The lowest energy dose for effective
defibrillation in infants and children is not
known. The upper limit for safe
dcfibrillation is also not known, but doses
>4 J/kg (as high as 9 J/kg) havc providcd
effectrvc dcfibrillation in childrcn and
animal models of pediatric arrest, with no
.i--i6^"-i,,,1.,^,--
-ff^^r-
AEDs with relativcly high energy doscs
l)x\ e becn used succcssfully rn inlants in
cardiac anest, with no clear adverse cflects_
O 2010 American I{eaft Association. BLS IICP lnterirn Materials. Use for AHA BLS HCP Courses until 201I BLS HCp materials are
released.
Table
1
Summary of Key BLS Components for Adults, Children, and Infants*
Recognition
No brealhing or no norma
breathing (e, only gasping)
No breathing or only gasping
No pulse palpated w th n T 0 seconds for all ages (HCP only)
C-A-B
Compression rate
Comprcssion depth
Chest wall .ecoil
Cornpression interruptions
Airway
At least 100/min
At least % AP diameier
About 2lnches (5 cm)
At least 2 inches (5 cm)
At least % AP diameter
AboLrt 1% inches (4 cm)
A 1o\"' complete recoil between compresslons
HCPs rotate corapressors every 2
flnutes
Minlmize interruptions ln chest compress ons
Attempt to limit interrruptions to <10 seconds
Head
tt
chln
(HCP suspected trauma:law ihrust)
lLfl
30:2
Single rescuer
Compression-to-ventilation
ratio (until advanced
airway placed)
15:2
2 HCP rescuers
Venlilations: when rescuer
untrained or trained and
nolfrofic:elt
Compressjons only
1 breath every
Ventilations \,\,ith advanced
airway (HCP)
Defibrillation
6
B
seconds (8-10 breaths/min)
Asynchronous with chest compressions
Aboul 1 second per breath
V sible chest rlse
Atlach and use AED as soon as ava ab e. Min rnrze rnterrupiions n chest compressions before and after shock;
resume CPR begrnning wilh compressions rnmed ate y after each shock
required to deliver the first cycle of 30 chest compressions, or
approximately 18 seconds; when 2 rescuers are present for
resuscitation of the infant or child. the delay wi'l be even snoded.
l\4ost victims of out-of-hospital cardiac arrest do not receive
any bystander CPR. There are probably many reasons for this,
but one impediment may be the A-B-C sequence, which starts
with the procedures that rescuers find most difficult, namely,
opening the airway and delivering breaths. Starting with chest
compressions nright encourage more rescuers to begin CPR.
Basic life support is usually described as a sequence oJ
actions, and this conlinuos to be true for the lone rescuer.
lMost healthcaro providers, howevor, work ln teams, and
team members typically pertonll Bl.S a(jiions sitirultaneously.
For example, one rescuer irn lg(lialtely irritiates chest
A Change From A-B-C to C-A-B
The 2010 AHA Guidelines for CPR and ECC recommend a
change in the BLS sequence of steps fi-om A-B-C (Airwayl
Breathing, Chest compressions) to C-A-B (Chest compressions,
Airway, Breathing) for adults, children, and in{ants (excluding the
newly born; see Neonatal Resuscitation section). This fundamental
change in CPB sequence will require reeducation ot everyone
who has ever learned CPR, but the consensus of the autllors and
experts involved in the creation of the 2010 AHA Guidelines for
CPF and ECC is ihat the benefit will justify the etfod.
!4/hy"- The vasi majority of cardiac arrests occur in adults,
and the highest survival rates frorn cardiac arrest are reported
among patients of all ages who have a witnessed arrest and
an initial rh!4hm of ventricular fibrillation (VR or pulseless
ventricular tachycardia MD. In these patients, the critical
initial elernents of BLS are chest compressions and early
defibrillation. In the A-B-C sequence, chest compressions
are often delayed while the responder opens the airway lo
give mouth-to mouth breaths, retrieves a barrier device, or
gathers and assembles ventilation equipment. By changing the
sequence to C A B, chest compressions will be initiated sooner
and the delay in ventilation should be minimal (ie, only the time
Figure
1
AHA ECC Adult Ghain of Survival
The links in the new AHA ECC Adult
Chain of Survival are as follows:
1. lmmediate recognition of cardiac
arrest and activation of the
emergency response system
2,
Early CPR with an emphasis on
chest compressions
3. Rapiddefibrillation
4. Effective advanced life support
5. Integrated pest-cardiac arresl care
@ American
Heart Association
compressions whtla anoth€r toscrrr'r gclli iln lutomated
external defibrillator (AED) and crllsr lor help, and a third
rescuer opens the airway anci I)rovi(los vontilations.
Healthcare providers are agair] {rrocxrri lleti to tallor rescue
actions to the mosl likely cause of irrrosl [:or example,
if a lone healthcare provider witnoss(,s it viclim suddenly
collapse, the provider may assurlr(l tlrat llrl) vi(ltirrl has had a
primary cardiac arrest with a shockill)lo tlrylhrr and should
immediately activate the emergency rosponso system,
retrieve an AED, and return to the victiI]r to provide CPF
and use the AED. But for a presurnocl vr(lirn ol asphyxial
arrest such as drowning, the priority woul(l bo to provide
chest compressions with rescue brl]atlrirtal Ior llbout 5 cycles
(approximately 2 minutes) before activatitr0 the emergency
response system.
Two new oads in the 2010 AHA Guidelines lor CPB and ECC
are Post-Cardiac Arrest Care and Educatiott, lrnplementation,
and Teams. The imDortance of post-cardiac arresl care is
emphasized by the addition of a new iitth link ir) lhe AHA
ECC Adult Chain of Survival (Figure 1). See the sections
Post-Cardiac Arrest Care and Education, lmplementation,
and Teams in this publication for a summary of key
recommendations contained in these new parts.
LAY RESCUER
ADULT CPR
Figure 2
Simplified Adult BLS Algorithm
Summary of Key Issues and Major Changes
No breathing or
Key issues and major changes for the 2010 AHA Guidelines for
CPF and ECC recommendations for lay rescuer adult CPF are
the following:
.
.
The simplified unjversal adult BLS algorithm has been
created (Figure 2).
Refinements have been made to recommendations for
immediate recognition and activaiion of the emergency
response system based on signs of unresponsiveness, as
well as initiation of CPR if the victim is unresponsive with no
breathing or no normal breathing (ie, victim is only gasping).
.
"Look, listen, and feel for breathing" has been removed from
the algorithm.
.
Coniinued emphasis has been placed on high-quality CPR
(with chest compressions of adequate rate and depth,
allowing complete chest reco I afier each compression,
minimizing interruptions in compressions, and avoiding
excessive ventilation).
.
.
#l$l,3li"",
response
tr\
-
There has been a change in the recommended sequence
for the lone rescuer to initiate chest compressions before
giving rescue breaths (C A-B rather than A-B-C). The lone
rescuer should begin CPF with 30 compressions rather than
2 ventilatrons to reduce delay 10 first compression.
Compression rate should be at least 100.hin (rather than
"approximately" 1 00/min).
.
no normal breathing
{only saspins)
Compression depth for adults has been changed from the
range of 1y21o 2 inches to at least 2 inches (5 cm).
These changes are designed to simplity lay rescuer training
and to continue to emphasize the need to provide early chest
compressions for lhe victim of a sudden cardiac arrest. More
information about these changes appears below. Nofe: ln the
following topics, changes or poinis of emphasis for lay rescuers
that are similar to those for healthcare providers are noted with
an asterisk (.).
Emphasis on Chest Compressions*
2O1O (New): lf a bystander is not trained in CPR, the bystander
should provide Hands-OnlyrM (compression-only) CPB for
the adult victjm who suddenly collapses, with an emphasis to
"push hard and fast" on the center of the chest, or follow the
directions of the El\.4S dispatcher. The rescuer should continue
Hands-Only CPR until an AED arrives and is ready for use or
EMS providers or other resDonders take over care of the victim.
All trained lay rescuers should, at a minimum, provide chest
compressjons for victims of cardiac arrest. In addition, if
the trained lay rescuer is able to pedorm rescue breaths,
compressions and breaths should be provided in a ratio of
30 compressions to 2 breaths. The rescuer should continue
CPR until an AED arrives and is readv for use or E[,4S Droviders
take over care of tire victim.
2OO5 (Qld): The 2005 AHA Guidelines for CPF and ECC
did not orovide different recommendations for trained versus
untrained rescuers but did recommend that disDatchers Drovide
compression-only CPR instructions to untrained bystanders.
The 2005 AHA Guidelines for CPR and ECC did note that if
the rescuer was unwilling or unable to provide ventilations, the
rescuer should provide chest compressions only.
!yhy.' Hands-Only (compression-only) CPF is easier for an
unlrained rescuer to perform and can be more readily guided
by dispatchers over the telephone. In addition, survival rates
from cardiac arrests of cardiac etiology are similar with ejther
Hands-Only CPR or CPR with both compressions and rescue
breaths. However, for the trained lay rescuer who is able, the
recommendation remains for the rescuer to pedor..n both
compressions and ventilations.
Highlights of the 2OlO AHA Guidelines for CPR and ECC @
r-t r-r-\ | /\_--r^
Ptr.UIAIHIU
BASI(j LIFE SUPPORT
Summary of Key lssues and Major Changes
lvlany key issues in pediatric BLS are the same as those in
adult BLS. These include the following:
.
.
.
.
.
.
Initiation of CPR with chest compressions rather than rescue
breaths (C-A-B rather than A-B-C); beginning CPR with
compressions rather than ventilations leads to a shorter delay
to first compression,
Continued emphasis on provision of high-quality CPR.
Modification of recommendations regarding adequate depth
of compressions to at least one third of the anterior-posterior
diameter of the chest; this corresponds to approximately
17, inches (about 4 cm) in most infants and about 2 inches
(5 cm) in most children.
Flemoval of "look, listen, and feel for breathing" from
rne sequence.
De-emphasis of the pulse check for heaithcare providers:
Additional data suggest that healthcare providers cannot
quickly and reljably determine the presence or absence of a
pulse. For a child who is unresponsive and not breathing, if
a pulse cannot be detected within 10 seconds. healthcare
providers should begin CPR.
Use oJ an AED for infants: For infants, a manual detibrillalor
is preferred to an AED for defibrillation. lf a manual
defjbrillator is not available, an AED equipped wlth a
pediatric dose attenuator is preferred. lf nelther is available,
an AED without a pediatric dose attenuator mav be used.
Life-Threatening Emergencies
Overview
This section describes 4 major life-threatening emergencies:
.
.
.
.
Cardiac arrest
Heart attack
Stroke
Choking (foreign-body airyvay obstruction)
Learning Objectives
At the end of this section you lvill be able to describe 4 life-threatening emergencies.
Cardiac Arrest
In cardiac arrest, circulation ceases and vital organs do not get enough oxygen. The viclim
will not be breathing and will not have a pulse.
Victims in cardiac arrest often have agonal gasps. Do not confuse agonal gasps with
adequate breathing. Agonal gasps may occur early in cardiac arrest, but they do not constitute adequate breathing. They are ineffective and will not maintaln oxygeoation or
ventilation.3e
e1
Healthcare providers are taught to look for "adequate breathing," with the assumption
that they will be able to distinguish between agonal gasps or other inadequate respiratory
efforts and effective spontaneous breathing.
Heart Attack
A heart aftack (myocardial infarction) occurs when an area of lhe heart is deprived of
blood Jlow and oxygen tor a prolonged period (usually more than 20 to 30 minutes) and
the heart muscle begins to die, causing chest discomfort or pain. A heart attack is usually
the result of
.
.
Severe narrowing of a coronary artery by cholesterol plaque
Cracking or erosion of plaque with the formation of a blood clot over il, leading to
complete blockage of the diseased coronary artery
Blood vessel spasm (either spontaneous or secondary to drugs such as cocaine) blocks
blood flow to heart muscle, causing a heart attack.
When blood flow to the heart muscle is blocked for a sufficient period, the muscle is
damaged from inadequate oxygen supply. lf blood flow through the adery is not quickly
restored, the hearl muscle cells supplied by that artery will begin to die.
lschemic heart muscle (muscle that does not receive sufficient oxygen) may develop
abnormal electrical rhy'thms, including ventricular tibrillation (VF). Out-of-hospital cardiac
arrest from heart attack most often develops within the first 4 hours after onset ol
symptoms. For this reason it is extremely important to activate the emergency response
system when symptoms of new or prolonged angina (unrelieved by rest and nitroglycerin)
or nocturnal angina develop.
ttRed Flagstt or
Warning Slgrns of
Chest discomfort is the most important signal of a heart attack. The discomfort lasts
more than 15 to 20 minutes and is not relieved-or is only paftially relieved-by rest
or nitroglycerin.s'? Some people describe intense pain, bul this is not universal.
Heart Attack
Other signs may include sweating, nausea, vomiting, or shortness of breath.
A {eeling of weakness may accompany chest discomfon.
Signals of a heart attack can develop in either gende( even in young adults, at any
lime and in anv Dlace.
Atypical
Presentations
of Heart Attack
The elderly,e3 people with diabetes, and womene'ls6 are more likely than others to present
unusual symptoms or only vague, nonspecitic complaints. Some people may present with
only weakness. Symptoms such as shodness of breath, syncope, or lightheadedness may
be the only symptoms in people with diabetes.
ln a long-term follow-up of the Framingham study, one third of first infarctions in men and
half of those in women were clinically unrecognized.s/ About one half of lhese were truly
silent, but the other 50o/o had atypical presentations.,s
The BLS provider must be aware of the many ways that people may present heart attacks
even in the absence of typical signs and symptoms.
Stroke
Recognizing the signs and symptoms of stroke is critical to early intervention and treatment. The presentation of stroke may be subtle. Signs and symptoms of stroke may
include
.
Sudden numbness or weakness of the face, arm, or leg, especially on one side of the
ooov
Sudden confusion, trouble speaking or understanding
Sudden trouble seeing in one or both eyes
Sudden trouble walking, dizziness, loss of balance or coordination
Sudden severe headache with no known cause
Choking
Early recognition of foreign-body airway obstruction (FBAO), or choking, is the key to successful outcome. lt is important to distinguish this emergency from fainting, stroke, heart
attack, seizure, drug overdose, or other conditions that cause sudden respiratory failure
but require different treatment. The trained observer can often detect signs of choking. For
more information on choking, refer to the choking sections earlier in this manual.
Rescuer Position
Position yourself at the victim's side so that you are ready to
.
.
Performing the Head
Tilt-Chin Lift
Open the airway
Begin giving breaths to the victim
Follow these steps to perform a head
tilt{hin lift (Figure
3):
Place one hand on the victim s forehead and push with your palm to tilt the
head back.
Place the fingers of the other hand under the bony part of the lower jaw near
the chin.
Lift the jaw to bring the chin forward.
AB
Figufe 3.
The head tilt-chin lift relieves airway obstruction in the unresponsive victim. A, Obstruction
by the tongue. When a victim is unresponsive, lhe tongue can block the upper airway. B, The head tiltchin lifl maneuver litts the tongue, relieving alrway obstruction.
Caution: Things
to Avoid lAftth
Head Tilt-Chin Lift
.
Do not press deeply into the soft tissue under the chin because this might obstruct the
airway.
.
.
Do not use the thumb to lift the chin.
Do not close the victim's mouth completely (unless mouth-to-nose breathing is the
technique of choice for the victim).
Recognizing Choking
in the Responsive
Infant
Early recognition of airway obstruction is the key to successful outcome. The trained
observer can often detect signs of choking.
Foreign bodies may cause a range of symptoms from rnlld to seyere airway obstruction.
Signs:
. Good air exchange
. Responsive and can cough forcefully
. lvlay wheeze between coughs
.
.
Relieving ehoking in
the Responsive Infant
Do not interfere with the victim's own
attempts lo expel the foreign body,
but stay with the victim and monitor
his or her condition.
Signs:
.
.
r
Poor or no air exchange
Weak, ineffective cough or no cough
.
at all
Higlr-pitched noise while inhdling or
.
.
.
.
no noise at all
Increased respiratory difficulty
Possible cyanosis (turning blue)
Unable to cry
Unable to move air
lf the victim cannot make any sounds
or breathe, severe airway obstruction
is present and you must activate the
emergency response system.
lf mild airway obstruction persists,
activate the emergency response
system.
Ciearing an objeci from an infant's airway requires a combination of back staps and chest
thrusts.
Follow these steps to relieve choking in a responsive infant:
Kneel or sit with the infant in your lap.
lf it is easy to do, bare the infant's chest.
Hold the infant prone (facedown) with the head slightly lower than the chest,
resting on your forearm. Support the infant's head and jaw with your hand.
Take care to avoid compressing the soft tissues of the infant's throal. Rest
your forearm on your lap or thigh to support the infant.
Deliver up to 5 back slaps (Figure 41A) forcefully in the middle of the back
between the infant's shoulder blades, using the heel of your hand. Deliver
each slap with sufficient force to attempt to dislodge the foreign bod.,.
After delivering up to 5 back slaps, place your free hand on the infant's back,
supporting the back ol the infant's head with the palm of your hand. The
infant wjll be adequately cradled between your 2 forearms, with the palm oI
one hand supporting the face and jaw while the palm of the other hand suppotls the back of the infant's head.
6
Turn the infant as a unit while carefully supporling the head and neck. Hold
tlte jnfant on his back 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 418) in the same locataon as chest compressions- just below the nipple line. Deliver chest thrusts
at a rate of about 1 per second, each with the intention of creating enough of
an "artificial cough" to dislodge the foreign body.
a
Figufe 41.
Relieving Choking
in the Unresponsive
,tt
t aTn a
Repeat the sequence of up to 5 back slaps and up to 5 chest thrusts until
the object is removed or tl're infant becomes unresponsive.
Rehef of choking in the infant. A. Back slaps. B. Chest thrusls.
Do not perform blind finger sweeps in infants and children because the foreign body may
be pushed back into the airway, causing further obstruction or injury67s
lf the infani victim becomes unresponsive, you will stop giving back slaps and will begin
CPR. Chest compressions give effective pressure in the chest and may be able to relieve
lhe obstruction.
To relieve choking in an unresponsive inlant, perlorm the following steps:
Place the infant on a firm, flat surface.
Open the infant's airway and look for an object in the pharynx. lf an object is
visible, remove it. Do not perform a blind finger sweepBegin CPR 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, remove it.
After approximately 5 cycles (about 2 minutes) of CPR, activate the emergency response system.
Review Question
1. For a responsive choking infant, use
obstruction.
_
and
_
to try io remove the airway