ADULT BASIC LIFE SUPPORT &

CARDIOPULMONARY RESUSCITATION (CPR)

Emma McAllister. Newcastle University

CLINICAL SKILLS AND COMMUNICATION

PRACTICAL SESSION

Basic Life Support and Cardiopulmonary Resuscitation will be covered on several occasions
during phase 1.
Stage 1
There will be a 1 hour lecture, followed by a 2 hour practical in semester 1
Semester 2, there will be a 2 hour practical with the introduction of “the choking patient”.
There is also a 1 hour first aid lecture.
Stage 2
There is a 2 hour practical with introduction of ethics

There is also opportunity to practice during revision sessions

Introduction 2
BLS Algorithmn 3
AED/Assessment 4
Detail of assessment 5, 6, 7, & 8
Cardiopulmonary Resuscitation 8, 9 & 10
Additional Information 11
Recovery position 12
Choking 13
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INTRODUCTION

Basic Life Support (BLS) & CARDIOPULMONARY RESUSCITATION (CPR) are important
skill s that may be called upon both in the hospital and the community setting.
The purpose of the Resuscitation Council (UK) guidance is to provide evidence-based
interventions that are most likely to prevent cardiac arrest or increase the chances of the
successful resuscitation (with full neurological recovery) of a casualty in cardiac or
respiratory arrest.
The prompt initiation and continuation of Basic CPR by competent bystanders considerably
reduces avoidable deaths after cardiac arrest.
During the CPR training session, the casualty (Mannequin) is assumed to be unconscious,
without spontaneous breathing and without pulse.
Staff will demonstrate basis CPR skills on the mannequin.
In the clinical skills lab you will be issued with a face shield for use when carrying out mouth to
mouth. You must keep this for the whole of the session. It prevents cross contamination with
colleagues. There are wipes available to clean the mask after use.
If you have any open cuts, grazes or wounds in or around your mouth (serum or blood) or
have any infectious diseases/illnesses then please DO NOT perform mouth to mouth
ventilation on the mannequin without using a face shield .
If using masks please ask one of your tutors for a single use only filter and discard of this
at the end of the session in the clinical waste bag.

PRINCIPLE

A cardiac arrest is the ultimate medical emergency. The correct treatment must be given
immediately if the patient is to have any chance of surviving.
The interventions that contribute to a successful outcome after a cardiac arrest can be
conceptualised as a chain – the Chain of Survival.
Any break in the continuity of this chain increases the likelihood of an adverse outcome.

You will learn about post resuscitation care in phase 2

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BASIC ADULT CPR ALGORITHMN

The Resuscitation Council (UK) provides a pathway for basic life support that we will follow
during your training.
The BLS algorithm will be explained in details.
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AUTOMATED EXTERNAL DEFIBRILLATOR—AED

One most important factor in survivability is getting a defibrillator to a casualty.

Many modern defibrillators are user-friendly automatic external defibrillators (AEDs).
AEDs are widely available in public places. In fact the first public access AED in the UK was in
the Metrocentre, Gateshead on 17th April 2000.
We will cover how to operate and use an AED during the lecture and practical session but
please remember, defibrillation of any type should not delay or replace chest compressions and/
or breaths .
Please note you will be shown how to use one of these but will not be assessed on the
use of this, you will however be expected to know that you need one.

This is an AED similar to the

type used in the clinical skills

ASSESSMENT

Assessment of acutely unwell patients follows an ABC approach, (Airway, Breathing, Circula-
tion) and in phase 2 will also learn DE (Disability, Exposure/examination).
For Basic Life Support we use DRS,ABC and this stands for :-
D—Danger
R—Response
S—Shout for help
A—Airway
B—Breathing
C—Circulation
The following part will explain the procedure of basic life support in detail as you may proceed in

DRS,ABC
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ADULT BASIC LIFE SUPPORT & CARDIOPULMONARY

D- DANGER

If a person is found collapsed. First always assess the surrounding environment for
danger and ask yourself
“Is it safe to approach the casualty?”.
Approach the casualty only if it is safe!
Think of some dangers that might be around

R—RESPONSE

Check if the casualty is responsive by shouting loudly “HELLO, CAN YOU HEAR ME?” whilst
applying a gentle physical stimulus, such as gently shaking the casualty at their shoulders.
If a patient is unconscious– they will NOT respond
Patients who do respond will be discussed later in the booklet

S—SHOUT FOR HELP

If he is unresponsive:
Shout for help, loudly and clearly and assertively “Can I get some help please”
At this stage you have a patient who is unresponsive, you now need to assess ABC
If possible, remove any tight clothing from the casualty quickly and safely.

A—AIRWAY

 Open the casualty’s mouth to visualise the upper airway.

 Use the head tilt-chin lift manoeuvre
Head tilt
 Place your hand on the victims forehead and gently tilt his head back
Chin lift
 With your fingertips under the point of the patients chin, lift the chin up to open the
airway
Dentures– if they are present and well-fittied, they should be left in place as they provide an
enhanced oral skeleton, helping to maintain airway patency
If there is an obvious foreign body in the upper airway, then it may be appropriate to remove said
body from the oropharyngeal cavity by using forceps or suction devices (healthcare setting only).
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RESUSCITATION (CPR)

A—AIRWAY CONTINUED

N.B. If there is any suspicion of injury to the cervical spine or in a trauma patient, the head-tilt
chin lift manoeuvre should be avoided if possible. Instead, a manoeuvre known as a jaw thrust
should be performed to maintain airway patency.
This will be demonstrated and explained further during the practical session.
Airway patency and adequate ventilation is the overriding priority.

Correct technique for head tilt—chin lift Jaw thrust for suspected cervical spine
Injury. Not recommended to be performed
by lay people

Once you have opened up the airway, you should immediately move on to assessment of
breathing

B—BREATHING

Use the Look, Listen and feel method

Check for normal breathing by:
Looking for the chest wall rising and falling
Listening with your ear for normal breath sounds
Feeling with your cheek above the casualty’s mouth
Ensure you are maintaining airway patency with a head-tilt chin lift manoeuvre.
Check for normal breathing for up to 10 seconds.
Abnormal breathing
In the first few seconds/minutes following cardiac arrest patients can breath noisily and
infrequently. This is Agonal breathing and should not be confused as normal breathing. If your
patient is not breathing normally Then you need to move on to the next stage.
Agonal breathing is present in up to 40% of cardiac arrest victims

You now know you have an unresponsive patient who is not breathing normally!
You need some definitive medical assistance
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CARDIOPULMONARY RESUSCITATION

GET MEDICAL HELP!

Community setting
Ask your helper to:
 Ring an ambulance (999—UK, 112—International)
 Tell the ambulance service that
 You have an unresponsive adult, not breathing or a suspected cardiac arrest
 Your location (Clinical Skills Lab– Newcastle Medical School)
 Any other relevant information
 Tell your helper to look for an AED (usually in places with high public volume)
 Tell your helper to return to you
It is important that your helper remain calm and speaks clearly to the ambulance service
N.B. Where AEDs are available there will usually be someone trained to use it. Circum-
stances however may vary and if an AED is available with no trained operator then you may
want to use the device yourself.

Hospital setting
Ask your helper to:
 Ring the crash/arrest team (2222, in all hospitals. This puts you in touch with emergency
switchboard operator who will answer immediately)
 Tell them:
 You have an ADULT cardiac arrest (paediatric if a child).
 Your location (Ward 20, bay 4)
 Any other relevant information
 Tell your helper to:
 Wait for the operator to repeat the information back to them to check it is correct
 Bring back the crash/arrest Trolley
 Be prepared to tell them where to locate the nearest one (It is important on your
clinical placements that you know where they are situated. Not every ward will
have its own)

Crash Trolleys are equipped with lots of different equipment and drugs.
They will have a defibrillator on it. You are NOT allowed to use this type of defibrillator
Defibrillation is a post graduate/training programme learning outcome.
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C—CIRCULATION

The current Resuscitation Council Guidelines express that only trained health professionals
need to assess for the presence or absence of a circulation by feeling for a pulse.
Medical students are not regarded as such and therefore you are not required to assess
circulation or a pulse as part of your basic life support provision.
However, in phase 2 and as Doctors you will be expected to accurately check a pulse when
assessing a collapsed or unwell casualty. Therefore, you are advised to practice this important
skill early in preparation for your future training and practice.
Assessing Circulation
An assessment of circulation is performed whilst simultaneously assessing breathing.
(This saves valuable time)
Whilst looking, listening and feeling for breath sounds, you should:
 Place your index and middle finger over the location of the carotid pulse in the neck
 Feel for a pulse for no more than 10 seconds.
If you are in anyway unsure about the pulse, but the patient IS NOT breathing normally—then
you must commence CPR

If you are on your own and no help has arrived, use your mobile phone to call for an ambulance.
Leave the victim only when no other option exists for getting help.

CPR—CARDIOPULMONARY RESUSCITATION

Sequence
30:2
30 chest compressions
2 Rescue breaths

Chest Compressions
It is important that you first perform chest compressions at a rate of 100-120 per minute and a
depth of approximately 5-6 cm.
 Place the heel of your hand in the centre of the chest on the lower half of the sternum
 Avoid the bottom end or abdomen (this no longer needs to be measured but is
approximately 2 finger breaths from the xiphisternum).
 The heel of your other hand should be placed on top, with your fingers interlaced.
 Your elbows should be locked and your body weight directed over the casualty’s chest.
 If your shoulders are not directly over your hands then your chest compressions are
usually of poor rate or quality and therefore inadequate. You may also tire prematurely.
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CPR—CARDIOPULMONARY RESUSCITATION

Chest compressions Continued

Chest compressions are the single most important aspect of CPR and can be performed without
the need for any equipment.
They take priority over rescue breaths and can be practised alone (compression only
CPR).
They ‘buy time’ by aiding perfusion of vital organs in an arrested casualty, until equipment such
as drugs and a defibrillator are available.
If you are unable to or unwilling to provide ventilation/ rescue breaths then compression
only technique should be used. This will be explained during the practical session/lecture.

After 30 chest compressions, attempt 2 adequate rescue breaths are performed.

If the rescue breaths are unsuccessful then move on, don’t waste time trying to establish
2 effective breaths

Rescue Breaths:
In hospital, pocket masks or special ambu-bags are normally provided.
In the community, you may be without these aids and may choose to perform direct mouth-to-
mouth ventilation.
Mouth to Mouth Ventilations
If equipment such as a pocket mask or ambu-bag is unavailable, you may choose to perform
direct mouth-to-mouth ventilations.
To perform mouth-to-mouth ventilations:
 Maintaining head tilt and chin lift
 Close casualty’s nostrils using the soft part of the nostrils
 Let the casualty’s mouth come open, but maintain chin lift
 Take a breath
 Seal your mouth around the casualty’s lips
 Breathe into the patient’s mouth.
 Watch for the chest to rise and fall
 Take about a second to make the chest rise
This technique is important as over-ventilation of the casualty may cause air to pass into their
stomach, causing them to vomit and subsequently compromise their airway further.
Repeat a second time

Chest compressions are then continued

The ratio is 30:2
It should take less then 5 seconds for your transition from rescue breaths to chest compressions
CPR should continue until the paramedic team arrive and take over or the casualty shows signs
of life.
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Mouth to Mask Ventilation

 Maintain airway patency with the head-tilt chin lift manoeuvre,
 Apply the face mask over the mouth and nose
 Obtain a firm seal with the casualty’s face, ensuring that you do not press on the soft
tissues of the neck but instead the bony jaw.
 Take a breath
 Perform rescue breath, breathing into the top of the mask
 Ensure you have a good seal.

Pocket mask for mouth- to- mask Ambu bag.

Ventilation. Found on Crash Trollies. A 2 person technique
Found on the walls of most wards is required to use this unless specially trained

SUMMARY

Remember DRS,ABC
D—Danger. Make sure you have a safe approach
R—Response. Ask if they can hear you, gently tap/shake them
S—Shout for help. Shout loudly and clearly for assistance
A—Airway. Check the airway for foreign bodies etc
B—Breathing. Look, listen, feel for normal breathing for up to 10 seconds
 Not breathing normally
 Get your help to ring for medical assistance
 Return with AED/Crash trolley
C—Circulation. Assess while assessing for breathing for a carotid pulse
If patient is in cardiac arrest. Commence Cardiopulmonary resuscitation
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ADDITIONAL INFORMATION

When to stop
 Stop to recheck the victim only if he starts to show signs of regaining consciousness,
such as coughing, opening his eyes, speaking, or moving purposefully AND starts to
breathe
normally; otherwise do not interrupt resuscitation.
 When help arrives
 When you are exhausted
If you have help then swap chest compressions every 2 minutes as you will become exhausted
and you compressions will be less effective.

Using an AED
If you obtain an AED and there is nobody trained there to use it, you will be expected to use it.
Open it up and simply follow the verbal instructions that it gives you.
There are sometimes scissors in the box so you can easily remove clothing.
The AED will instruct you.

Agonal Breathing
Agonal breaths are abnormal breaths that are commonly heard during the first few minutes of
cardiac arrest.
Agonal respiration is an abnormal pattern of breathing characterized by shallow, slow (3-4 per
minute), irregular inspirations followed by irregular pauses.
It may also be characterized by gasping, laboured breathing, accompanied by strange
vocalizations and myoclonus (involuntary twitching of a muscle).

ADDITIONAL STUDENT NOTES

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THE RECOVERY POSITION

The breathing patient

If a casualty is unresponsive or drowsy but found to be breathing normally with a pulse present
then a casualty should be carefully placed in the recovery position:
It is unsafe to leave an unresponsive or drowsy casualty on their back as if they vomit they may
aspirate or compromise their airway.
Finally you should continue to reassess the casualty as per the basic life support algorithm in
case the clinical situation changes.

Remove the victim’s glasses, if present.

Kneel beside the victim and make sure that both their
legs are straight.
Place the arm nearest to you out at right angles to
their body, elbow bent with hand palm-up.
Bring the far arm across the chest, and hold the back
Place arm nearest you at right angles
of the hand against the victim’s cheek nearest to you.
With your other hand, grasp the far leg just above the
knee and pull it up, keeping the foot on the ground.
Keeping their hand pressed against his cheek, pull on
the far leg to roll the casualty towards you on to their
side.
Adjust the upper leg so that both the hip and knee are
bent at right angles.
Bring the far arm over and place back of
Tilt the head back to make sure that the airway
hand on their cheek
remains open.
If necessary, adjust the hand under the cheek to keep
the head tilted and facing downwards to allow liquid
material to drain from the mouth.
Check breathing regularly!
After placing the casualty in the recovery position,
attract help.
You may need to leave the patient in the recovery Pull the knee up and roll them towards
position and get help. you
Finally you should continue to reassess the casualty
as per the basic life support algorithm in case the
clinical situation changes.
If the casualty has to be kept in the recovery position
for more than 30 min turn them to the opposite side to
relieve the pressure on the lower arm.
Regularly check that the patient is
Adapted from Resus Council (UK) 2010 breathing normally
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THE CHOKING PATIENT

The choking casualty

If faced with a conscious choking casualty you should attempt to remove the obstructing foreign
body using the following algorithm:
 First encourage the patient to cough forcefully
 If this fails to dislodge the foreign body proceed to perform five forceful backslaps in the
centre of the upper back between the scapulae
 Further failure to dislodge the foreign body warrants the use of the abdominal thrusts
(formally known as Heimlich manoeuvre). Abdominal thrusts aim to raise both intra-
abdominal and intra-thoracic pressure in an attempt to expel a foreign body from the
airway.
 If at any point the casualty becomes unconscious then you need to assess the
casualty, call an ambulance or crash team immediately and commence CPR.
Please note that the abdominal thrust (Heimlich manoeuvre) is only useful in the conscious
patient as it must be performed with the patient sitting or standing as your fist is drawn inwards
and upwards towards you.
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REFERENCES

Resuscitation Council UK Website

www.resus.org.uk

LEARNING OUTCOMES

Stage 1 semester 1
 Demonstrate the initial assessment of the collapsed casualty/patient using the
recommended technique
 Demonstrate effective BLS on a mannequin according to current Resuscitation Council
(UK) guidelines
 Demonstrate the correct technique for cardiac compressions, mouth to mouth and mouth
to mask ventilations using a mannequin
 Place an unconscious casualty into the recovery position using the recommended
technique
 Recognise the need for an AED (Automated External Defibrillator)
 Describe how the basic BLS technique may be modified to protect the casualty and
rescuer from potential harm

Stage 1 semester 2
 All of the above
Plus
 Demonstrate the initial assessment of a conscious choking adult
 Using a mannequin, demonstrate the recommended technique of back blows and
abdominal thrusts to relieve choking
 Demonstrate what further actions to take if the choking adult loses consciousness

Stage 2 semester 2
 All of the learning outcomes previously covered