CPR Chpt 13

stridor

high-pitched sound caused by partial obstruction of the air passageway

advanced life support (ALS)

which involves advanced lifesaving procedures, such as cardiac monitoring, administration of intravenous (IV) fluids and medications, and the use of advanced airway adjuncts.

cardiac rhythm disturbances

(dysrhythmia), such as ventricular fibrillation (V-fib) or pulseless ventricular tachycardia (V-tach). The normal heart rhythm is known as normal sinus rhythm. V-fib is the disorganized quivering of the ventricles, resulting in no forward blood flow and a state of cardiac arrest. V-tach is a rapid contraction of the ventricles that does not allow for normal filling of the heart. As mentioned previously, according to the AHA, early defibrillation is the link in the chain of survival that is most likely to improve survival rates. The likelihood of survival decreases rapidly over time as long as V-fib or pulseless V-tach persists.

hyperventilation

(ventilating too fast or with too much force) may cause increased intrathoracic pressure (pressure inside the chest cavity). Increased intrathoracic pressure reduces the amount of blood that returns to the heart, thus decreasing the effectiveness of chest compressions and resulting in the heart and brain receiving decreased amounts of oxygen.

breathing

A lack of oxygen (hypoxia), combined with too much carbon dioxide in the blood (hypercarbia), is lethal. To correct this condition, you must provide slow, deliberate ventilations that last 1 second. This gentle, slow method of ventilating the patient prevents air from being forced into the stomach (discussed later in the chapter).

infant CPR

. Take standard precautions. Place the infant on a firm surface, using one hand to keep the head in an open airway position. You can also use a pad or wedge under the shoulders and upper body to keep the head from tilting forward. 2. Imagine a line drawn between the nipples. Place two fingers in the middle of the sternum, just below the nipple line Step 1. 3. Using two fingers, compress the sternum at least one-third the anterior-posterior diameter of the chest (approximately 1.5 inches [4 cm] in most infants). Compress the chest at a rate of 100 to 120 per minute. 4. After each compression, allow the sternum to return briefly to its normal position. Allow equal time for compression and relaxation of the chest. Do not remove your fingers from the sternum, and avoid jerky movements Coordinate compressions and ventilations in a 30:2 ratio if you are working alone, and 15:2 if you are working with a trained bystander or another health care provider. Ensure the infant's chest fully recoils in between compressions and that the chest visibly rises with each ventilation. You will find this easier to do if you use your free hand to keep the head in the open airway position. If the chest does not rise, or rises only a little, then use a head tilt-chin lift to open the airway. Reassess the infant for signs of spontaneous breathing or a pulse after five cycles (about 2 minutes) of CPR.

Steps for CPR

1. First, restore circulation by performing chest compressions to circulate blood to the vital organs of the body. 2. Next, perform 30 high-quality compressions to a depth of 2 inches to 2.4 inches (5 cm to 6 cm) in an adult at the rate of 100 to 120 per minute. Next, open the airway with the jaw-thrust or head tilt-chin lift maneuver. 3. Last, restore breathing by providing rescue breaths (via mouth-to-mask ventilation or a bag-valve mask [BVM]). Administer 2 breaths, each over 1 second, while visualizing for chest rise.

The five links in the chain of survival

1. Recognition and activation of the emergency response system, 2.Immediate, high-quality CPR, 3.Rapid defibrillation 4.Basic and advanced emergency medical services. 5.Advanced life support and postarrest care If any one of the links in the chain is not maintained, then the patient is more likely to die.

Proper Hand Position and Compression Technique

1. Take standard precautions. 2. Place the heel of one hand on the center of the chest over the lower half of the sternum Step 1. 3. Place the heel of your other hand over the first hand Step 2. 4. With your arms straight, lock your elbows and position your shoulders directly over your hands, so that the thrust of each compression is straight down on the sternum. Your technique may be improved or made more comfortable if you interlock the fingers of your lower hand with the fingers of your upper hand; either way, keep your fingers off the patient's ribs. 5. Depress the sternum to a depth of 2 inches to 2.4 inches (5 cm to 6 cm), using direct downward movement and then rising gently upward Step 3. This motion allows pressure to be delivered vertically from your shoulders. Downward pressure produces a compression that must be followed immediately by an equal period of relaxation. The ratio of time devoted to compression versus relaxation should be 1:1. It is important that you allow the chest to return to its normal position; do not lean on the patient's chest between compressions. Compression and relaxation should be of equal duration. Complications from chest compressions are rare but can include fractured ribs, a lacerated liver, and a fractured sternum

one-rescuer CPR

1. Take standard precautions. Establish unresponsiveness and call for additional help; use your mobile phone if needed Step 1. 2. Position the patient properly (supine) on a flat surface. 3. Quickly visualize the chest for signs of breathing while simultaneously palpating for a carotid pulse. Take no more than 10 seconds in total to do this Step 2. 4. If pulse and breathing are absent, then perform CPR until an AED is available. Place your hands in the proper position for delivering external chest compressions, as described previously Step 3. Give 30 chest compressions at a rate of 100 to 120 per minute for an adult. Each set of 30 compressions should take about 17 seconds. 5. Open the airway according to your suspicion of spinal injury Step 4. 6. Give two ventilations of 1 second each and observe for visible chest rise Step 5. 7. Continue cycles of 30 chest compressions and two ventilations until additional personnel arrive or the patient starts to move.

Two person CPR

1. Take standard precautions. Establish unresponsiveness while your partner moves to the patient's side to be ready to deliver chest compressions Step 1. 2. If the patient is unresponsive, then simultaneously check for breathing and palpate for a carotid pulse; take no more than 10 seconds to do this Step 2. 3. If the patient is not breathing and has no pulse, then begin CPR, starting with chest compressions. Give 30 chest compressions at a rate of 100 to 120 per minute. If an AED is available, then apply it and follow its voice prompts. Do not interrupt chest compressions to apply the AED pads Step 3. 4. Open the airway according to your suspicion of spinal injury Step 4. 5. Give two ventilations of 1 second each and observe for visible chest rise Step 5. 6. Perform five cycles of 30 compressions and two ventilations (this should take about 2 minutes). After 2 minutes of CPR, the compressor and ventilator should switch positions. The switch time should take no longer than 5 seconds. Reanalyze the patient's cardiac rhythm with the AED every 2 minutes and deliver a shock if indicated. 7. Continue cycles of 30 chest compressions and two ventilations until ALS providers take over or the patient starts to move.

Mechanical piston device

A mechanical piston device is a device that depresses the sternum via a compressed gas-powered or electric-powered plunger mounted on a backboard. The patient is positioned supine on the backboard, with the piston positioned on top of the patient with the plunger centered over the patient's thorax in the same manner as with manual chest compressions. The device is then secured to the backboard. The mechanical piston device allows rescuers to configure the depth and rate of compressions, resulting in consistent delivery. This frees the rescuer to complete other tasks and eliminates rescuer fatigue that results from continuous delivery of manual chest compressions. These devices have been available for many years. The latest versions of these devices offer you the option of providing compressions using a battery instead of an oxygen tank or a compressed air system, thus eliminating the tanks and hoses.

return of spontaneous circulation (ROSC)

A successful resuscitation is defined not only by ROSC but also the survival of the patient to hospital discharge.

2nd set of wisdom

AEDs are becoming more accessible in the community. Be familiar with your local protocols on pediatric defibrillation. Your service may use a pediatric AED or an AED with a pediatric adapter. Remember, if the child is past the onset of puberty, follow the adult CPR sequence, including the use of adult-sized AED pads.

AED's in children

AEDs can safely be used in children using the pediatric-sized pads and a dose-attenuating system (energy reducer). However, if these items are unavailable, use adult-sized AED pads. Apply the AED to infants or children after the first five cycles of CPR have been completed. Recall that cardiac arrest in children is usually the result of respiratory failure; therefore, oxygenation and ventilation are vitally important. After the first five cycles of CPR, use the AED to deliver shocks in the same manner as with an adult patient. If the patient is an infant (between 1 month and 1 year of age), then a manual defibrillator is preferred to an AED; however, this is an ALS skill. As with any cardiac arrest situation, call for ALS backup immediately. If ALS backup with a manual defibrillator is unavailable, then an AED equipped with pediatric-sized pads and a dose attenuator is preferred. If neither is available, then use an AED with adult-sized pads. If you use adult-sized AED pads on an infant or small child, then do not cut the pads to adjust the size. Instead, use the anterior-posterior placement, following the manufacturer's recommendation.

checking for breathing and a pulse in peds pts

After you establish responsiveness, you need to assess breathing and circulation. As with an adult, this assessment can occur simultaneously and should take no longer than 10 seconds. Visualize the chest for signs of breathing and palpate for a pulse in a large central artery. You can usually palpate the carotid or femoral pulse in children older than 1 year, but it is difficult in infants. Therefore, in infants, palpate the brachial artery, which is located on the inner side of the arm, midway between the elbow and shoulder. Place your thumb on the outer surface of the arm between the elbow and shoulder. Then place the tips of your index and middle fingers on the inside of the biceps, and press lightly toward the bone. CPR will be required if the infant or child is not breathing or is not breathing normally (agonal gasps), and a pulse is absent (or less than 60 beats/min).

Check for Breathing and a Pulse

After you have determined that the patient is unresponsive, quickly check for breathing and a pulse. These assessments can occur simultaneously and should take no longer than 10 seconds in total. Visualize the chest for signs of breathing while palpating for a carotid pulse. Feel for the carotid artery by locating the larynx at the front of the neck and then sliding two fingers toward one side (the side closest to you). The pulse is felt in the groove between the larynx and sternocleidomastoid muscle, with the pads of the index and middle fingers held side by side: Light pressure is sufficient to palpate the pulse.

Respiratory and cardiac arrest differences

Although cardiac arrest in adults usually occurs before respiratory arrest, the reverse is true in infants and children. In most cases, cardiac arrest in children results from respiratory arrest. If untreated, respiratory arrest will quickly lead to cardiac arrest and death. Respiratory arrest in infants and children has a variety of causes, discussed later in this chapter.

gastric distention

Artificial ventilation may result in the stomach becoming filled with air, a condition called gastric distention. Gastric distention is likely to occur if you hyperventilate the patient. If you ventilate too forcefully, or if the patient's airway is not opened adequately, then the excess gas opens up the collapsible tube (the esophagus) and allows gas to enter the stomach. Therefore, it is important for you to give slow, gentle breaths. Such breaths are also more effective in ventilating the lungs. Excessive inflation of the stomach is dangerous because it can cause the patient to vomit during CPR. It can also reduce lung volume by elevating the diaphragm. If massive gastric distention interferes with adequate ventilation, then contact medical control. Check the airway again and reposition the patient, watch for rise and fall of the chest, and avoid giving forceful breaths. Have a suction unit available in case the patient vomits. Remember, mortality increases significantly if aspiration occurs. If an ALS provider is available, then he or she can insert an orogastric or nasogastric tube to decompress the stomach.

Assessing the Need for BLS

As always, begin by surveying the scene. Is the scene safe? How many patients are present? What is your initial impression of the patient(s)? Are bystanders present who may have additional information? What is the mechanism of injury or nature of illness? Do you suspect trauma? If you were dispatched to the scene, then does the dispatch information match what you see? Because of the urgent need to start CPR in a pulseless, nonbreathing patient, you must complete a primary assessment as soon as possible and begin CPR, starting with chest compressions. The first step is to determine unresponsiveness. Gently tap the patient on the shoulder and shout, "Are you okay?" Clearly, a patient who is responsive does not need CPR. A person who is unresponsive may or may not need CPR. Continue your assessment by simultaneously checking for breathing and a pulse; this step should take no more than 10 seconds. If the patient is in cardiac arrest, then begin CPR immediately.

positioning--

As with an adult, an infant or child must be lying on a hard, flat surface for effective chest compressions. If you need to carry an infant while providing CPR, then your forearm and hand can serve as the flat surface. Use your palm to support the infant's head. In this way, the infant's shoulders are elevated, and the head is slightly tilted back in a position that will keep the airway open. Ensure that the infant's head is not higher than the rest of the body. The technique for chest compressions in infants and children differs from adults because of a number of anatomic differences, including the position of the heart, the size of the chest, and the fragile organs of a child. The liver (immediately under the right side of the diaphragm) is relatively large and fragile, especially in infants. The spleen, on the left, is smaller and more fragile in children than in adults. These organs are easily injured if you are not careful in performing chest compressions, so be sure that your hand position is correct before you begin. The chest of an infant is smaller and more pliable than that of an older child or adult; therefore, you should use only two fingers to compress the chest. If two rescuers are performing CPR on an infant, use the two-thumb-encircling-hands technique to deliver chest compressions. In children, especially those older than 8 years, you can use the heel of one or both hands to compress the chest.

Avoid interruptions

Chest compressions create blood flow to the heart through filling of the coronary arteries. Every time compressions are stopped, blood flow—and thus, perfusion—to the heart (and brain) drops to zero. It takes 5 to 10 compressions to reestablish effective blood flow to the heart after chest compressions are resumed. Avoid frequent or prolonged interruptions in chest compressions, which lead to poor patient outcomes.

children--

Children consume oxygen two to three times as rapidly as adults, so you must first focus on opening the airway and providing artificial ventilation. Often, this will be enough to allow the child to resume spontaneous breathing and, thus, prevent cardiac arrest. Therefore, airway and breathing are the focus of pediatric BLS

CPR--

Compressions should be between 2 and 2.4 inches in depth (5 to 6 cm) and given at a rate of 100 to 120 per minute. The chest should completely recoil between each compression to maximize blood return to the heart. The rescuer should never lean on the chest between compressions. Interruptions between compressions for any reason should be minimized. If any one of the links in the chain is not maintained, then the patient is more likely to die.

responsive infants and foreign body

Do not use abdominal thrusts on a responsive infant with an airway obstruction because of the risk of injury to the immature organs of the abdomen. Instead, perform back slaps and chest thrusts to try to clear a severe airway obstruction in a responsive infant, as follows . Hold the infant facedown, with the body resting on your forearm. Support the infant's jaw and face with your hand, and keep the head lower than the rest of the body. 2. Deliver five back slaps between the shoulder blades, using the heel of your hand. . Place your free hand behind the infant's head and back, and turn the infant faceup on your other forearm and thigh, sandwiching the infant's body between your two hands and arms. The infant's head should remain below the level of the body. 4. Give five quick chest thrusts in the same location and manner as chest compressions, using two fingers placed on the lower half of the sternum. For larger infants, or if you have small hands, you can perform this step by placing the infant in your lap and turning the infant's whole body as a unit between back slaps and chest thrusts. 5. Check the airway. If you can see the foreign body, then remove it. If not, then repeat the cycle as often as necessary. 6. If the infant becomes unresponsive, then begin CPR and follow the same sequence as for a child and adult.

When NOT to start CPR

First, do not start CPR if the scene is unsafe. The concept of ensuring scene safety applies in cardiac arrest situations, just as it does on any other call. Second, do not start CPR if the patient has obvious signs of death. Recall from Chapter 3, Medical, Legal, and Ethical Issues, that obvious signs of death include an absence of a pulse and breathing, along with any one of the following findings: ▪ Rigor mortis, or stiffening of the body after death ▪ Dependent lividity (livor mortis), a discoloration of the skin caused by pooling of blood Figure 13-26 ▪ Putrefaction (decomposition of the body tissues) ▪ Evidence of nonsurvivable injury, such as decapitation, dismemberment, or being burned beyond recognition. Rigor mortis and dependent lividity develop after a patient has been dead for a long period, DNR.

Positioning the patient

For CPR to be effective, the patient must be lying supine on a firm, flat surface, with enough clear space around the patient for two rescuers to perform CPR and use the AED. If the patient is crumpled up or lying facedown (prone), then you will need to move him or her to a supine position. Be mindful that you cannot rule out a spinal injury in an unresponsive patient; therefore, protect the patient's neck and move him or her as a unit, without twisting. If the patient is found in a bed, then move him or her to the floor. If possible, log roll the patient onto a long backboard as you position him or her for CPR; do this as quickly and safely as possible. A backboard will provide support during transport and emergency care. After the patient is properly positioned, you can easily assess the patient to determine whether CPR and defibrillation are necessary.

Age differencces

For the purposes of BLS, anyone younger than 1 year is considered an infant. A child is between 1 year of age and the onset of puberty (approximately 12 to 14 years of age), as signified by breast development in girls and underarm, chest, and facial hair in boys. Adulthood is from the onset of puberty and older. Children vary in size. Some small children may best be treated as infants, some larger children as adults. There are two basic differences in providing CPR for infants, children, and adults. The first is that the emergencies in which infants and children require CPR usually have different underlying causes. The second is that there are anatomic differences in adults, children, and infants, such as smaller airways in infants and children than in adults.

spinal injury

If spinal injury is suspected, then use the jaw-thrust maneuver. Do not tilt the patient's head back, because you want to minimize movement of the patient's neck. To perform a jaw-thrust maneuver, place your fingers behind the angles of the patient's lower jaw and then move the jaw upward. Keep the head in a neutral position as you move the jaw upward and open the mouth. If the patient's mouth remains closed, then you can use your thumbs to pull down the patient's lower lip to allow breathing. If the jaw thrust fails to open the airway, then the head tilt-chin lift should be used to open the airway. An open airway is the primary goal when caring for trauma patients, and you must ensure an open airway to improve survival

rescue breathing

If the child is not breathing but has a pulse, then open the airway and deliver one breath every 3 to 5 seconds (12 to 20 breaths/min) If the child is not breathing and does not have a pulse, then deliver 2 rescue breaths after every 30 chest compressions (15 chest compressions if two rescuers are present). Each ventilation should last about 1 second and should produce visible chest rise. Use the proper-sized mask and ensure an adequate mask-to-face seal.

▶ Recovery Position

If the patient is breathing adequately on his or her own and has no signs of injury to the spine, hip, or pelvis, then place him or her in the recovery position. This position helps to maintain a clear airway in a patient with a decreased level of consciousness who has not sustained traumatic injuries and is breathing adequately on his or her own It also allows vomitus to drain from the mouth. Roll the patient onto his or her side so that the head, shoulders, and torso move as a unit, without twisting. Then place the top hand under his or her cheek. Never place a patient who has a suspected head or spinal injury in the recovery position because in this position, the spine is not aligned, spinal stabilization is not possible, and further spinal injury could result. Likewise, if the patient has a hip or pelvic injury, then positioning the patient on his or her side could cause fractured bone ends to compress or sever large arteries and veins, resulting in severe internal bleeding. You should suspect an associated spinal injury in any unresponsive patient with a hip or pelvic injury until proven otherwise.

Words of wisdom

If you witness a patient's cardiac arrest and an AED is available, then deploy the AED immediately and then begin CPR. However, if you did not witness the patient's cardiac arrest or if an AED is unavailable, then perform CPR and apply the AED as soon as it is available. If two or more rescuers are present, one rescuer should begin CPR while the other prepares to defibrillate using the AED.

breathe rate

Infants and children should be ventilated once every 3 to 5 seconds, (at a rate of 12 to 20 breaths/min). Do not ventilate too fast or use too much force.

heart location

It is critical to perform compressions properly. Chest compressions are administered by applying rhythmic pressure and relaxation to the lower half of the sternum. The heart is located slightly to the left of the middle of the chest between the sternum and the spine Compressions squeeze the heart, thereby acting as a pump to circulate blood. Allow the chest to completely recoil between compressions, which enhances blood return to the heart. Do not lean on the chest between compressions. When artificial ventilation is provided, the blood that is circulated through the lungs during chest compressions is likely to receive adequate oxygen to maintain tissue perfusion. However, even when external chest compressions are performed properly, they circulate only one-third of the blood that is normally pumped by the heart.

changing positions

It is critical to switch rescuers during CPR to maintain high-quality compressions. After five cycles of CPR (about 2 minutes), the rescuer providing compressions to the patient (the compressor) will begin to tire, and compression quality will decrease. Therefore, compressors should switch positions every 2 minutes. If there are only two rescuers on scene, then the two rescuers will alternate positions. If additional rescuers are available, the compressor should rotate every 2 minutes. During switches, every effort should be made to minimize the time that no compressions are being administered. It should take less than 5 seconds to switch compressors. The switch between the two rescuers can be easily accomplished. Rescuer one (the first compressor) should finish the cycle of 30 compressions while the second rescuer moves to the opposite side of the chest and moves into position to begin compressions. Rescuer one should deliver two rescue breaths and then rescuer two should take over compressions by administering 30 chest compressions. Rescuer one will then deliver two ventilations and the CPR cycles will continue as needed until the next 2-minute mark (five cycles) is reached, at which time the process will be repeated.

determining responsiveness peds

Never shake a child to determine whether he or she is responsive, especially if the possibility of a neck or back injury exists. Instead, gently tap the child on the shoulder, and say loudly, "Are you okay?" Figure 13-22. With an infant, gently tap the soles of the feet. If a child is responsive but struggling to breathe, then allow him or her to remain in whatever position is most comfortable. If you find an unresponsive, apneic, and pulseless child while you are alone and off duty, and you did not witness the child's collapse, perform CPR beginning with chest compressions for approximately five cycles (about 2 minutes), and then stop to call 9-1-1 and retrieve an AED. Do not call 9-1-1 right away, as you would with an adult. Remember that cardiopulmonary arrest in children is most often the result of respiratory failure, not a primary cardiac event. Therefore, children will require immediate restoration of oxygenation, ventilation, and circulation, which can be accomplished by immediately performing five cycles (about 2 minutes) of CPR before activating the EMS system.

Remember

Remember, brain cells die every second that they are deprived of oxygen. Permanent brain damage is possible after only 4 to 6 minutes without oxygen

STOP mnemonic

S The patient Starts breathing and has a pulse. T The patient's care is Transferred to another provider of equal or higher-level training. O You are Out of strength or too tired to continue CPR. P A Physician who is present or providing online medical direction assumes responsibility for the patient and gives direction to discontinue CPR.

1 to onset of puberty

Take standard precautions. Place the child on a firm surface. Place the heel of one or two hands in the center of the chest, in between the nipples. Avoid compression over the lower tip of the sternum, which is called the xiphoid process Step 1. . Compress the chest at least one-third the anterior-posterior diameter of the chest (approximately 2 inches [5 cm] in most children) at a rate of 100 to 120 per minute. With pauses for ventilation, the actual number of compressions delivered will be about 80 per minute. In between compressions, allow the chest to fully recoil; do not lean on the chest. Compression and relaxation time should be the same duration. Use smooth movements. Hold your fingers off the child's ribs, and keep the heel of your hand(s) on the sternum. 3. Coordinate compressions and ventilations in a 30:2 ratio for one rescuer and 15:2 for two rescuers, making sure the chest rises with each ventilation. At the end of each cycle, pause for two ventilations Step 2. 4. After five cycles (about 2 minutes) reassess for a pulse. If there is no pulse and you have an AED, continue CPR and apply the AED pads. 5. If the child regains a pulse of greater than 60 beats/min and resumes effective breathing, place him or her in a position that allows for frequent reassessment of the airway and vital signs during transport

no spinal injury

The head tilt-chin lift maneuver is effective for opening the airway in most patients when there is no indication of a spinal injury

The load-distributing band (LDB)

The load-distributing band (LDB) is a circumferential chest compression device composed of a constricting band and backboard The device is either electrically or pneumatically driven to compress the heart by putting inward pressure on the thorax. As with the mechanical piston device, use of the LDB frees the rescuer to complete other tasks. The device weighs less than the early-version mechanical piston devices and can be easier to apply.

abdominal-thrust maneuver

The manual maneuver recommended for removing severe airway obstructions in responsive adults and children older than 1 year is the

Provide Artifical Ventilatioins

Ventilations can be given by one or two EMS providers. Use a barrier device when you administer ventilations in the prehospital environment, such as a pocket mask with a one-way valve or a BVM Figure 13-15. Use devices that supply supplemental oxygen when possible. Devices with an oxygen reservoir will provide higher percentages of oxygen to the patient. Regardless of whether you ventilate the patient with or without supplemental oxygen, you should observe the chest for visible rise to assess the effectiveness of your ventilations.

Wet Patients

Water conducts electricity. Therefore, the AED should not be used in water. If the patient's chest is wet, then the electrical current may move across the skin rather than between the pads to the patient's heart. If the patient is submerged in water, then pull him or her out of the water and quickly dry the skin before attaching the AED pads. Do not delay CPR to dry the patient thoroughly; instead, quickly wipe off as much moisture as possible from the chest. If the patient is lying in a small puddle of water or in the snow, the AED can be used, but again, the patient's chest should be quickly dried as much as possible.

pacemakers and implanted defibrilators

You may encounter a patient who has an automated implanted cardioverter-defibrillator (AICD) or pacemaker that delivers shocks directly to the heart if necessary. These devices are used in patients who are at a high risk for certain cardiac dysrhythmias and cardiac arrest. It is easy to recognize AICDs or pacemakers because they create a hard lump beneath the skin, usually on the upper left side of the chest (just below the clavicle). If the AED pads are placed directly over the device, then the effectiveness of the shock delivered by the AED may be reduced, and the shock could potentially damage the implanted device. Therefore, if you identify an AICD or pacemaker, then you should place the AED pads at least 1 inch (2.5 cm) away from the device. Occasionally, the implanted device will deliver shocks to the patient. If you observe the patient's muscles twitching as if he or she was just shocked, then continue CPR and wait 30 to 60 seconds before delivering a shock from the AED.

Transdermal medication patches

You may encounter a patient who is receiving medication through a transdermal medication patch, such as nitroglycerin. The medication is absorbed through the skin. The patch could reduce the flow of the electrical current from the AED to the heart and may burn the skin. If the medication patch interferes with AED pad placement, then remove the patch with your gloved hands and wipe the skin to remove any residue prior to attaching the AED pad.

ischemia

decreased oxygen supply

review of adult bls procedures

irculation Pulse check Carotid artery Compression area In the center of the chest, in between the nipples Compression depth 2 in. to 2.4 in. (5 cm to 6 cm) Compression rate 100 to 120/min Compression-to-ventilation ratio (until advanced airway is inserted) 30:2 Foreign body obstruction Responsive: abdominal thrusts (Heimlich maneuver); chest thrusts if patient is pregnant or has obesity Unresponsive: CPR Airway Airway positioning Head tilt-chin lift; jaw-thrust maneuver if spinal injury is suspected Breathing Ventilations 1 breath every 5 to 6 seconds (10 to 12 breaths/min); about 1 second per breath; visible chest rise Ventilations with advanced airway placed 1 breath every 6 seconds (a rate of 10 breaths/min)

Active compression-decompression CPR

is a technique that involves compressing the chest and then actively pulling it back up to its neutral position or beyond (decompression). This technique may increase the amount of blood that returns to the heart, and thus, the amount of blood ejected from the heart during the compression phase. Figure 13-18 shows an active compression-decompression CPR device. It features a suction cup that is placed in the center of the chest. After compressing the chest to the proper depth, the rescuer pulls up on the handle of the device to provide active decompression of the chest, thus ensuring that the chest returns to at least its neutral position or even beyond neutral.

impedance threshold device (ITD)

is a valve device placed between the ET tube and a BVM; it may also be placed between the bag and mask if an ET tube is not in place. The ITD is designed to limit the air entering the lungs during the recoil phase between chest compressions Figure 13-19. This results in negative intrathoracic pressure that may draw more blood toward the heart, ultimately resulting in improved cardiac filling and circulation during each chest compression. The ITD may be considered when used together with devices that provide active compression-decompression CPR. It is not currently recommended for use with conventional CPR. If ROSC occurs, then the ITD should be removed. You should understand research trends regarding the effectiveness of the ITD.

BLS

is noninvasive emergency life-saving care that is used to treat medical conditions, including airway obstruction, respiratory arrest, and cardiac arrest. BLS follows a specific sequence for adults and for infants and children. This care focuses on the ABCs: airway (obstruction), breathing (respiratory arrest), and circulation (cardiac arrest or severe bleeding). If the patient is in cardiac arrest, then a CAB sequence (compressions, airway, breathing) is used because chest compressions are essential and must be started as quickly as possible Ideally, only seconds should pass between the time you recognize that a patient needs BLS and the start of treatment.

ventilation

is the physical act of moving air in and out of the lungs. Ventilation is required for adequate respiration. Examples of conditions that hinder ventilation include trauma such as flail chest, foreign body airway obstruction, and an injury to the spinal cord that disrupts the phrenic nerve that innervates the diaphragm.

Chest compression fraction

is the total percentage of time during a resuscitation attempt in which chest compressions are being performed. Make every effort to maintain a chest compression fraction of at least 60% (the higher the better). The more frequent the interruptions in chest compressions, the lower the compression fraction will be. Low compression fractions lead to worse patient outcomes. Most modern cardiac monitors will provide information about chest compression fraction that you can review after a cardiac arrest. If possible, routinely review this information after every arrest so that you can learn ways to improve the chest compression fraction and improve on other key performance indicators.

Cardiopulmonary resuscitation (CPR)

is used to establish circulation and artificial ventilation in a patient who is not breathing and has no pulse

BLS peds

table 13-2