Appendix A Suppport

Cardiopulmonary Resuscitation and Basic Life

The steps of basic life support (BLS) consist of a series of actions and skills performed by the rescuer(s) based on assessment findings. The first action performed by the rescuer upon finding an adult victim is to assess for responsiveness. This is accomplished by tapping or gently shaking the victim's shoulder and asking, Are you all right? If the victim does not respond and the rescuer is alone, the rescuer should activate emergency medical services (EMS), get an automatic external defibrillator (AED) (if available), return to the victim, and begin cardiopulmonary resuscitation (CPR) and defibrillation if necessary.1 The American Heart Association includes training in the use of AEDs with instruction of health care personnel and laypersons in BLS. Survival from cardiac arrest is the highest when immediate CPR is provided and defibrillation occurs within 3 to 5 minutes.1 AEDs now can be found in many out-of-hospital, public settings (Fig. A-1).

FIG. A-1 airport.

Automatic external defibrillator (AED) located in an

Airway
The next step in BLS is to assess the victim's airway to confirm the absence of breathing and to establish a patent airway. Fig. A-2 demonstrates opening the airway and performing mouth-to-mouth ventilation. An adult's airway is opened by hyperextending the head. The head tiltchin lift maneuver is used and involves tilting the head back with one hand and

lifting the chin forward with the fingers of the other hand. If the victim is gasping occasionally or not breathing, the rescuer attempts to ventilate the victim with mouth-tobarrier (recommended) or mouth-to-mouth resuscitation.1

FIG. A-2 The head tiltchin lift maneuver is used to open the victim's airway to give mouth-to-mouth resuscitation. A, Rescuer places one hand on the victim's forehead and applies firm, backward pressure with the palm to tilt the head back. The chin is lifted and brought forward with the fingers of the other hand. B, Rescuer pinches the victim's nostrils, seals mouth over victim's mouth, and delivers a regular breath. Rescuer should observe for a rise in the victim's chest (arrow).

TABLE A-1 Management of Foreign Body Airway Obstruction (FBAO)

Conscious Adult Victim Assess Victim for Severe Airway Obstruction Signs of severe airway obstruction: Universal choking sign (victim clutches neck with hands) Inability to speak

Ask the victim, Are you choking? Silent cough High-pitched sound or no sound while inhaling Increased difficulty breathing Cyanosis

If the victim displays any of the above signs, severe or complete airway obstruction may be present and the rescuer must take action. Heimlich Maneuver (Abdominal Thrusts) with Standing/Sitting Victim (Fig. A-3) 1. 2. Stand behind victim and wrap arms around waist. Make fist with one hand.

3. Place thumb side of fist against victim's abdomen. Position fist midline, slightly above umbilicus and well below xiphoid process. 4. Grasp fist with other hand.

5. Press fist into victim's abdomen using quick upward thrusts. Each thrust should be a separate, distinct movement. Note: If victim is in the late stages of pregnancy or obese, chest thrusts should be used. Position hands (as described) over lower portion of the sternum and apply quick backward thrusts. 6. Repeat thrusts until object is expelled or victim becomes unresponsive.

Unconscious Adult Victim Assessment

If rescuer sees victim collapse and knows that FBAO is the cause: 1. 2. Activate the EMS system by calling 911. Be sure victim is supine.

3. Perform tongue-jaw lift; look to see if a foreign body is visible and, if seen, remove it (Fig. A-4). 4. Open airway and attempt to ventilate: Give two rescue breaths. If breaths are unsuccessful in making victim's chest rise: a. Reposition victim's head. b. Reopen airway. c. Reattempt to ventilate. 5. If efforts to ventilate are still unsuccessful, begin CPR (see Tables A-2 and A-3). Source: 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Part 4: Adult Basic Life Support, Circulation 112:IV-19, 2005.

FIG. A-3 Heimlich maneuver administered to a conscious (standing) victim of foreign body airway obstruction.

Breathing
Ventilations are given with the victim's nostrils pinched and the rescuer's mouth placed around the victim's mouth to make a tight seal. Face mask or bag-mask devices can also be used. Two breaths are given by the rescuer (1 second per breath). The volume of air of each ventilation should be equal to a regular breath and enough to produce a visible rise in the

victim's chest.1 When the victim has a tracheostomy, ventilation should be given through the stoma.

FIG. A-4 With the victim's head up, the rescuer grasps both the tongue and the lower jaw between the thumb and fingers and lifts (tongue-jaw lift). This action draws the tongue from the back of the throat and away from the foreign body. The rescuer looks to see if any foreign body is visible and, if seen, removes it.

If airflow is obstructed, the rescuer should reposition the head and repeat the attempt to ventilate. If the victim cannot be ventilated after repositioning the head, the rescuer should proceed with CPR. When providing rescue breaths, the rescuer should look for any foreign objects in the victim's mouth and remove them if visible (Table A-1).

In those rare instances when airway obstruction is not relieved, additional procedures are necessary. These include transtracheal catheter ventilation and cricothyroidotomy, which should only be attempted by health care professionals experienced in these procedures.1

Cardiac Compressions
Cardiac arrest is characterized by the absence of a pulse in the large arteries of an unconscious victim who is not breathing. Health care providers are instructed to perform a pulse check in victims that are unresponsive and not breathing. Lay rescuers are not taught this skill. Instead they are instructed to begin chest compressions immediately after delivering two rescue breaths. The carotid artery is used to determine the absence of a pulse. After an airway has been established and two ventilations have been delivered, the rescuer checks the pulse of the carotid artery. While maintaining the head-tilt position with one hand on the forehead, the rescuer locates the victim's trachea with two or three fingers of the other hand. The rescuer then slides these fingers into the groove between the trachea and the muscles of the side of the neck where the carotid pulse can be felt. The technique is more easily performed on the side nearest the rescuer. If a pulse is palpated, the rescuer should provide rescue breaths at a rate of 10 to 12 breaths/minute and recheck the pulse every 2 minutes. If no pulse is palpated within 10 seconds, chest compressions should be initiated.1 The proper technique for administering chest compressions is shown in Fig. A-5. Chest compression technique consists of serial, rhythmic applications of pressure on the lower half of the sternum. The victim must be in the supine position when the compressions are performed. The victim must be lying on a flat, hard surface, such as a CPR board (specially designed for use in CPR), a headboard from a unit bed, or, if necessary, the floor. The rescuer should be positioned close to the side of the victim's chest. The guidelines for proper compression technique are presented in Tables A-2 and A-3 and Fig. A-5. Rescue breathing and chest compressions are combined for an effective resuscitation effort of the victim of cardiopulmonary arrest. The compression-ventilation ratio for one- or two-person CPR is 30 compressions to 2 ventilations (see Tables A-2 and A3). If the patient is intubated and the airway is secure, compressions should not be paused for ventilations.1 It is preferable to have two persons performing CPR (see Table A-3). One person, positioned at the victim's side, performs chest compressions while the other rescuer, positioned at the victim's head, maintains an open airway and performs ventilations. In order to maintain the quality and rate of compressions, rescuers should change roles approximately every 2 minutes.1

FIG. A-5 Cardiopulmonary resuscitation (CPR). A, Position of the hands during application of cardiac compressions. B, When pressure is applied, the lower portion of the sternum is

displaced posteriorly with the palm of the hand. C, To apply maximum downward pressure, the rescuer leans forward so that both arms are at right angles to the patient's sternum and the elbows are locked.

Interruptions in CPR should be limited. When the AED or advanced cardiac life support (ACLS) team arrives, the victim's rhythm should be assessed. If the victim has a shockable rhythm (i.e., ventricular tachycardia or ventricular fibrillation), one shock should be delivered followed by five cycles of CPR before checking the rhythm. If the rhythm is not a shockable rhythm, CPR should be resumed and the rhythm rechecked every five cycles. CPR should continue between rhythm checks and shocks, and until the ACLS team arrives or the victim shows signs of movement.1 ACLS involves the use of detailed medical algorithms for the provision of lifesaving cardiac care in settings ranging from the pre-hospital environment to the hospital setting. Nurses are

often required to obtain ACLS certification in addition to BLS depending on their area of practice.

TABLE A-2 Adult One-Rescuer Cardiopulmonary Resuscitation (CPR)

Assess Determine unresponsiveness: Tap or gently shake shoulder. Shout, Are you all right? Activate Emergency Medical Services (EMS) System* Activate EMS system by calling 911 and get the AED (if available) (outside of hospital). Call a code and ask for the AED or crash cart (in the hospital). Airway Position the victim: a. Turn on back (if necessary) using logroll technique. Open the airway using proper technique: Head tiltchin lift maneuver (see Fig. A-2)

b. Jaw-thrust maneuver (if cervical spine injury is suspected); if unable to open airway using jaw-thrust maneuver, use head tiltchin lift maneuver. Breathing 1. 2. Assess for cessation of breathing: LOOK for chest rising and falling. LISTEN for air escaping during exhalation. FEEL for flow of air. If victim is breathing adequately: Continue to protect airway.

 3.

Place victim in recovery position. If victim is unresponsive and gasping occasionally or not breathing: Provide two regular breaths each over 1 second. a. Observe chest rise. b. Allow for complete exhalation between breaths.

If unable to give two effective breaths: a. Reposition victim to try to open airway. b. Look for foreign body and, if seen, remove. c. Reattempt to ventilate.

If ventilation is still unsuccessful, assess circulation.

If adequate spontaneous breathing is restored and signs of circulation are present: a. Maintain open airway. b. Place victim in recovery position. Circulation Lay Rescuer Begin chest compressions after delivering two initial breaths. Health Care Professional 1. 2. Assess for signs of circulation after delivery of the two initial breaths. Feel for carotid pulse (10 seconds).

3. If victim has signs of circulation but is not breathing adequately, continue rescue breathing (1 breath/5 to 6 seconds) and recheck circulation every 2 minutes. 4. If there are no signs of circulation, begin chest compressions.

Compression/Ventilation Compression-Ventilation Cycle

Compression-ventilation ratio is 30:2. Begin Compressions 1. Get into position for compressions at victim's side (by shoulders).

2. Locate landmark notch (hands in the center of chest, right between the nipples, and two fingers above the xiphoid-sternal notch). 3. 4. Position hands, arms, and shoulders. Elbows are locked and arms are straight. Rescuer's shoulders positioned directly over hands. Begin compressions: Compressions should depress victim's sternum approximately to 2 inches. Allow chest to rebound to normal position after each compression. Perform compressions hard and fast at the rate of 100 per minute. Maintain correct position at all times.

Provide Ventilation 1. Open airway using proper technique.

2. Deliver two slow regular breaths (1 second each) at the end of a cycle of 30 compressions. 3. 4. 5. Return hands to chest. Find proper landmark and hand position. Restart compressions.

Defibrillation If witnessed arrest, use AED as soon as possible. If unwitnessed arrest, deliver five cycles of CPR before using AED. If rhythm is shockable, deliver one shock, then resume CPR for five cycles before rechecking rhythm. If the rhythm is not shockable, resume CPR and recheck rhythm every five cycles.

Continuation of CPR CPR should be continued between rhythm checks and shocks, and until ACLS providers arrive or the victim shows signs of movement. Do not interrupt CPR except in special circumstances.

Source: 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Part 4: Adult Basic Life Support, Circulation 112:IV-19, 2005. ACLS, Advanced cardiac life support; AED, automatic external defibrillator. * Rescuers should phone 911 for unresponsive adults before beginning CPR, except in the case of drowning or a likely asphyxiation. Lay rescuers are no longer taught a pulse check.

TABLE A-3 Adult Two-Rescuer Cardiopulmonary Resuscitation (CPR)

Assess/Activate Emergency Medical Services (EMS) System* One Rescuer Determine unresponsiveness: Tap or gently shake shoulder. Shout, Are you OK? Other Rescuer Activate EMS system by calling 911 and get the AED (if available) (outside of hospital). Call a code and ask for the AED or crash cart (in hospital). Airway Position the victim: a. Turn on back (if necessary) using logroll technique. Open the airway using proper technique: Head tiltchin lift maneuver (see Fig. A-2).

b. Jaw-thrust maneuver (if cervical spine injury is suspected); if unable to open airway using the jaw-thrust maneuver, use the head tiltchin lift maneuver.

Breathing 1. 2. 3. Assess for cessation of breathing: LOOK for chest rising and falling. LISTEN for air escaping during exhalation. FEEL for flow of air. If victim is breathing adequately: Continue to protect airway. Place victim in recovery position. If victim is unresponsive and gasping occasionally or not breathing: Provide two regular breaths each over 1 second. a. Observe chest rise. b. Allow for complete exhalation between breaths. If unable to give two effective breaths: a. Reposition victim to try to open airway. b. Look for foreign body and, if seen, remove. c. Reattempt to ventilate. If ventilation is still unsuccessful, assess circulation.

If adequate spontaneous breathing is restored and signs of circulation are present: a. Maintain open airway. b. Place victim in recovery position. Circulation Lay Rescuers Begin chest compressions after delivering two initial breaths. Health Care Professionals 1. Assess for signs of circulation after delivery of the two initial breaths.

2.

Feel for carotid pulse (10 seconds).

3. If victim has signs of circulation but is not breathing adequately, continue rescue breathing (1 breath/5 to 6 seconds) and recheck circulation every 2 minutes. 4. If there are no signs of circulation, say No pulse and prepare for chest compressions. Compression/Ventilation Compression-Ventilation Cycle Compression-ventilation ratio is 30:2. One Rescuer/Compressor 1. Get into position for compressions at victim's side (by shoulders).

2. Locate landmark notch (hands in the center of chest, right between the nipples, and two fingers above the xiphoid-sternal notch). 3. 4. Position hands, arms, and shoulders: Elbows are locked and arms are straight. Rescuer's shoulders positioned directly over hands. Begin compressions: Compressions should depress victim's sternum approximately to 2 inches. Allow chest to rebound to normal position after each compression. Perform compressions hard and fast at the rate of 100 per minute. Maintain correct position at all times.

Other Rescuer/Ventilator 1. 2. Get into position at victim's head. Maintain an open airway.

3. Deliver two slow regular breaths (1 second each) at the end of a cycle of 30 compressions. 4. Ensure that chest is rising with each ventilation.

5.

Monitor carotid pulse during compressions to verify effectiveness.

Switching Rescuers should change compressor and ventilator roles every 2 minutes to avoid compressor fatigue. Rescuers should exchange positions simultaneously with minimal delay: Ventilator moves to chest. Compressor moves to head.

Defibrillation If witnessed arrest, use AED as soon as possible. If unwitnessed arrest, deliver five cycles of CPR before using AED. If rhythm is shockable, deliver one shock, then resume CPR for five cycles before rechecking rhythm. If the rhythm is not shockable, resume CPR and recheck rhythm every five cycles. Continuation of CPR CPR should be continued between rhythm checks and shocks, and until ACLS providers arrive or the victim shows signs of movement. Do not interrupt CPR except in special circumstances.

Source: 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Part 4: Adult Basic Life Support, Circulation 112:IV-19, 2005. ACLS, Advanced cardiac life support; AED, automatic external defibrillator. * Rescuers should phone 911 for unresponsive adults before beginning CPR, except in the case of drowning or a likely asphyxiation. Lay rescuers are no longer taught a pulse check.

REFERENCE
1. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Part 4: Adult Basic Life Support. Circulation. 112, 2005, IV,19. (Lewis, Sharon Mantik. Medical-Surgical Nursing (Single Volume): Assessment and Management of Clinical Problems, 7th Edition. Mosby, 032007. 70). <vbk:978-0-323-03690-0#outline(70)>