Chapter 4:
Basic Life Support for Adults and Children
Lesson Objectives
After completing this lesson, participants should be able to:
• Demonstrate how to position an unresponsive patient and open his or her airway.
• Demonstrate how to check for breathing and circulation in an unresponsive adult and child patient.
• Demonstrate how to deliver rescue breathing using mouth-to-mouth and mouth-to-barrier device methods.
• Discuss how to perform rescue breathing using mouth-to-nose and mouth-to-stoma methods.
• Demonstrate how to perform CPR on an adult and child patient.
• Identify causes and types of airway obstruction.
• Demonstrate how to manage an airway obstruction in a responsive adult or child patient.
• Demonstrate how to manage an airway obstruction in an unresponsive adult or child patient.
Approximate Time: 85 minutes
Skill Practice: Yes
DVD Covers Points in Lesson: Yes
PowerPoint™ Presentation Supports Points in Lesson: Yes
Teaching Points
• Begin your primary assessment of a motionless patient by checking responsiveness and assessing breathing. If an unresponsive patient is lying facedown, roll the patient, keeping the head, neck, and shoulders aligned to avoid twisting the body and aggravating a possible spinal injury.
• After the patient is positioned, tap him or her on the shoulder and shout, “Are you okay?” If the patient is unresponsive, call for help and quickly visualize the chest for signs of breathing.
• If an unresponsive patient is not breathing (or has agonal gasps), check for a pulse by locating the carotid artery at the side of the neck nearest you with your index and middle fingers.
• To feel the carotid pulse, locate the thyroid cartilage, slide your fingers toward you (into the groove at the side of the neck), and press gently. Feel for a pulse for at least 5 seconds but no more than 10 seconds.
• If a pulse is present, perform rescue breathing. If a pulse is absent, perform CPR starting with chest compressions.
• Before providing rescue breathing, you must open the patient’s airway. The tongue may be blocking the airway; in some cases, moving the jaw forward is all that is needed to restore breathing.
• Use the head tilt-chin lift maneuver to open the airway when no spinal injury is suspected. Place one hand, palm down, on the patient’s forehead and tilt the head back. Place two fingers of the other hand on the bony part of the patient’s chin and lift up. In children, be careful not to hyperextend the neck as you tilt the head back.
• Use the jaw-thrust maneuver if you suspect a spinal injury. Place your index and middle fingers on the angles of the lower jaw and your thumbs on the cheekbones. Move the jaw forward without tilting the head back.
• Carefully perform the head tilt-chin lift maneuver in a patient with a suspected spinal injury if the jaw-thrust maneuver is unsuccessful.
• To perform rescue breathing, blow air into the lungs of an apneic patient. You must continue to breathe for the patient if a pulse is present but he or she is not breathing at a rate of one breath every 3 to 5 seconds (12 to 20 breaths per minute) for children ages 1 to the onset of puberty and one breath every 5 to 6 seconds (10 to 12 breaths per minute) for adults.
• Deliver each rescue breath over a period of 1 second—just enough to produce visible chest rise. Do not hyperventilate the patient.
• If the chest does not rise, reposition the head and attempt to deliver another breath. If two attempts are unsuccessful, suspect an airway obstruction that needs to be cleared.
• Rescue breathing can be performed with mouth-to-barrier ventilation devices, more advanced ventilation devices, or just your mouth. To protect yourself against the limited risk of contracting an infectious disease through mouth-to-mouth contact, carry a barrier device in your vehicle when you are off duty in case an emergency occurs.
• Methods for performing rescue breathing:
Mouth-to-mask: Position yourself at the patient’s head. Open the patient’s airway. Place the mask over the patient’s mouth and nose. Using both hands, grasp the mask and the patient’s jaw. Press down on the mask with your thumbs as you lift up on the jaw with your fingers to create a good seal between the mask and face. Breathe into the one-way valve just enough to produce visible chest rise. Release pressure on the mask to allow air to escape.
Mouth-to-mouth: This is the least preferred method. Position yourself at the patient’s head. Open the patient’s airway. Pinch the patient’s nose closed. Make a tight seal by placing your mouth over the patient’s mouth. Give breaths using the same method as mask-to-mouth breathing, removing your mouth and unpinching the nose between breaths.
Mouth-to-nose: This is appropriate when you cannot open the patient’s mouth, when you cannot make a good seal around the mouth, when the mouth is severely injured, or when the patient’s mouth is too large or has no teeth. This method is performed in the same way as mouth-to-mouth rescue breathing, except you force air through the patient’s nose and open the mouth when possible to allow air to escape.
Mouth-to-stoma: This is used in a nonbreathing patient who has had a laryngectomy. When you breathe into the stoma, the patient’s mouth and nose must be closed to prevent air from entering the upper airway.
• CPR is a combination of chest compressions and rescue breaths. Begin CPR with chest compressions on an unresponsive patient who is not breathing (or has agonal gasps) until a defibrillator is available. CPR is also indicated if an unresponsive, nonbreathing child is pulseless or has a pulse of less than 60 beats per minute with signs of poor perfusion.
• To perform CPR on an adult:
Position the patient so he or she is flat on his or her back on a hard surface. Position yourself so that your knees are alongside the patient’s chest.
Place the heel of one hand in the center of the chest, in between the nipples. Place your other hand on top of the first. Lock your fingers together and pull upward so that only the heel of your hand is touching the patient’s chest.
Lean forward so your shoulders are directly over your hands and the patient’s sternum. Using the weight of your body, keep your arms straight and compress the sternum at least 2”. Allow the chest to fully recoil between compressions. Count each compression out loud and deliver them at a rate of at least 100 per minute. Each set of 30 compressions should take approximately 18 seconds or less.
After 30 compressions, open the airway and give two breaths (1 second each), ensuring that each breath produces visible chest rise.
Continue the cycles of 30 chest compressions and two breaths until a defibrillator arrives or the patient starts to move.
• To perform CPR on a child:
Position the patient so he or she is flat on his or her back on a hard surface. Position yourself so that your knees are alongside the patient’s chest.
Place the heel of one hand in the center of the chest, in between the nipples. Use two hands in larger children, as with an adult.
Lean forward so your shoulders are directly over your hand(s) and the patient’s sternum. Keep your arms straight and compress the chest at least one third its depth (about 2″). Allow the chest to fully recoil between compressions. Count each compression out loud and deliver them at a rate of at least 100 per minute. Each set of 30 compressions should take approximately 18 seconds or less.
After 30 compressions, open the airway and give two breaths (1 second each), ensuring that each breath produces visible chest rise.
Continue the cycles of 30 chest compressions and two breaths until a defibrillator arrives or the patient starts to move.
• Whenever possible, two providers should work together to perform CPR. This reduces provider fatigue and allows one provider to check for a pulse while the other performs chest compressions.
• In two-person CPR, one provider performs chest compressions and the second delivers rescue breaths. A compression to ventilation ratio of 30 to 2 should be used in adults, and a ratio of 15 to 2 should be used in children.
• When two providers are performing CPR, they should work on opposite sides of the patient so they can more easily switch functions after every 2 minutes to minimize provider fatigue. Positions should be changed quickly so that compressions are not interrupted for more than 5 seconds.
• When an advanced airway (King LT, LMA, Combitube, endotracheal [ET] tube) is in place during two-person adult or child CPR, the providers should not deliver “cycles” of CPR. Ventilate the patient at a rate of 8 to 10 breaths per minute (one breath every 6 to 8 seconds) and perform chest compressions at a rate of 100 per minute. Do not attempt to synchronize breaths and compressions; there should be no pause in chest compressions to deliver breaths.
• Discontinue CPR if return of spontaneous circulation (ROSC) occurs or signs of life return, another trained provider replaces you, a physician tells you to stop, you are too physically exhausted to continue, the scene becomes unsafe, or cardiac arrest lasts longer than 30 minutes (except in cases of severe hypothermia or cold water drowning).
• Rare complications may occur, even when CPR is performed correctly. These include fractures of the ribs or sternum, separation of the rib cartilage, bruising of the heart and lungs, puncture of the lungs, spleen, liver, or heart from fractured ribs, or ruptured lungs.
• You can minimize the risk of complications by paying careful attention to your “form.” Common mistakes made when performing CPR include failing to adequately open an airway, failing to maintain an open airway, failing to pinch the patient’s nosed closed or maintain an adequate seal over the nose and mouth, not providing adequate breaths or breathing too fast or too forcefully, completing CPR cycles too slowly or too quickly, not placing the patient on a hard or level surface, performing chest compressions with the elbows bent, performing chest compressions in the wrong location, using the wrong compression rate, and performing chest compressions that are too shallow, too deep, or with jerky movements.
• You must be able to quickly distinguish an airway obstruction (choking) from other causes of sudden respiratory failure. Immediate recognition and correction is the key to preventing hypoxia, loss of consciousness, and cardiac arrest.
• Common causes of airway obstruction include food, small objects (in children), the tongue (in unresponsive patients), and swelling of the airway passages. If unsure of the cause, assume it is a foreign body. If you believe swelling is the cause, request ALS personnel immediately.
• A patient with a mild (partial) airway obstruction has adequate air exchange. He or she is responsive, can cough forcefully, and may be able to speak with difficulty. Encourage the patient to cough, which will likely clear the obstruction. Do not interfere with the patient’s attempts to expel the obstruction. Remain with the patient and be prepared to intervene if his or her condition deteriorates.
• A patient with a severe (complete) airway obstruction has an airway that is completely blocked. He or she cannot speak, cough, cry, or breathe. The patient may display the universal distress sign for choking. His or her skin may become cyanotic, and he or she will lose consciousness within minutes. If the obstruction is not quickly removed, cardiac arrest will follow.
• To determine whether a responsive patient has an obstructed airway, see if he or she is able to talk and exchange air. If the patient cannot talk, perform abdominal thrusts (the Heimlich maneuver). If more than one provider is present, one should tend to the patient while the other summons help.
• To perform abdominal thrusts on a responsive adult or child:
Stand or kneel behind the patient and wrap your arms around his or her waist.
Make a fist with one hand and place the thumb side against the abdomen, just above the umbilicus and well below the sternum.
Grasp the fist with your other hand and give quick, inward and upward thrusts into the abdomen. This will often be enough to relieve the obstruction.
Continue until the obstruction is relieved or the patient becomes unresponsive.
• If the patient is obese or in the later stages of pregnancy, you should perform chest thrusts instead of abdominal thrusts.
• To perform chest thrusts:
Stand behind the patient with your arms under the patient’s armpits and wrap your arms around the chest.
Place the thumb side of one hand in the middle of the chest, in between the nipples.
Grasp the fist with your other hand and pull inward on the chest until the obstruction is relieved or the patient becomes unresponsive.
• When necessary, you can perform chest thrusts on a supine patient by kneeling close to him or her and delivering downward thrusts in the middle of the chest, in between the nipples.
• If the adult or child becomes unresponsive during your attempts at relieving an airway obstruction:
Carefully support the patient to the ground and immediately call (or send someone) for help.
Perform chest compressions immediately (do not check for a pulse), using the same landmark you would for CPR. If you are alone or the patient is an adult, perform 30 chest compressions; if two providers are present and the patient is a child, perform 15 compressions.
Open the airway and look in the mouth. If you see an object, attempt to remove it. If you do not see an object, attempt to ventilate.
If the first ventilation does not produce visible chest rise, reopen the airway and reattempt to ventilate.
If both breaths do not produce visible chest rise, continue chest compressions.
Continue until the obstruction is relieved or ALS personnel take over.
• After 2 minutes (about five cycles) of CPR, the provider should go for help if someone has not already done so.
• Once the obstruction is relieved and your breaths produce visible chest rise, check for a pulse. The patient may have been without oxygen long enough to cause cardiac arrest, which requires CPR.
Application
• Participants should demonstrate how to properly position an unresponsive patient and open the airway.
• Participants should demonstrate the proper steps for checking breathing and pulse in an adult or child patient.
• Participants should properly demonstrate how to give rescue breathing using mouth-to-mouth and mouth-to-barrier device techniques for adults and children.
• Participants should demonstrate the proper technique for performing one-person adult and child CPR.
• Participants should demonstrate how to perform two-person CPR.
• Participants should identify the common causes and signs of choking.
• Participants should demonstrate how to deliver abdominal thrusts to a responsive patient and how to manage an unresponsive patient with an obstructed airway.
• Participants should complete the “Check Your Knowledge” questions at the end of Chapter 4 in the textbook.
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