SAVING AMERICAN HEARTS, Inc.

Basic Life Support (BLS)

Study Guide

NEW 2020 Guidelines of the American Heart Association

This study guide was not created by the American Heart Association. It was created by Saving American Hearts and is intended to be a supplement to your provider manual.

WHEN YOU FIND AN UNCONSCIOUS ADULT

STEP 1: Assess scene safety. Always assess scene safety first. If the scene is not safe, it is reasonable to withhold resuscitation efforts.

STEP 2: Tap on both shoulders and shout "Hey are you ok?"

STEP 3: Activate the Emergency Response System and get an AED. If others are around, send someone to get help.

STEP 4: Assess breathing and pulse simultaneously: Check a carotid pulse for at least 5 seconds but no more than 10. If there is no pulse or you are not sure if you feel a pulse, begin chest compressions.

Compress at a depth of at least 2 inches or 5 cm for adults and children but no more than 2.4 inches or 6 cm

Compress at a rate of at least 100-120 compressions per minute. Push hard and fast.

Make sure you allow the chest to completely recoil between compressions.

After 30 compressions, give 2 breaths. If there is no suspected head or neck injury: Perform a "head tilt chin lift" and give 2 breaths. If you suspect a neck injury: Perform a "jaw thrust" to open the airway and deliver 2 breaths.

Give each breath over 1 second watching for chest rise. Do not give large breaths. You want to see the chest just begin to rise. If you give breaths that are too large, all that extra air will go into the stomach. After several large breaths, the pressure will begin to increase in stomach which will then crush the lungs, heart and the diaphragm making it more difficult to save your patient and they will most likely vomit.

Give cycles of 30 compressions and 2 breaths. 5 cycles = two minutes

STEP 5: After 2 minutes, reassess the pulse. If there is no pulse, resume chest compressions and breaths for 2 more minutes. Every two minutes check a pulse. If you are not alone, switch roles every two minutes. The person giving compressions will now maintain the airway and give breaths. The person who was giving breaths will now take over chest compressions.

ONCE THE AED ARRIVES

When an AED arrives, use it.

Step 1: Turn on the AED. It may take up to 5-15 seconds to warm up.

Step 2: Follow the instructions given by the AED. Continue chest compressions and breaths while listening to the AED.

STEP 3: Place the pads on the patient following the pictures on the pads for correct placement. If you are not alone, continue chest compressions and have someone else place the pads. If the chest is hairy, the pads may not stick, if you have 2 sets of pads, put them on the patient and pull them off quickly to remove the hair. If you only have one set of pads, look in your AED kit for a razor, scissors, and quickly remove some of the hair, and replace the pads.

STEP 4: When the AED says "ANALYZING RHYTHM, DO NOT TOUCH THE PATIENT" make sure no one is touching the patient, not even the person giving breaths. If the AED says "SHOCK ADVISED, CHARGING" continue chest compressions while the AED is charging.

STEP 5: When the AED is charged, clear the patient and deliver the shock. Immediately resume chest compressions. Begin with 30 compressions and 2 breaths. Complete 5 cycles of 30 compressions and 2 breaths. When 2 minutes have passed, the AED will automatically reanalyze the rhythm. If the AED says: "NO SHOCK ADVISED" you do not check a pulse, you immediately resume CPR for 2 more minutes. Continue these steps until more advanced help arrives. Every time the AED reanalyzes the rhythm, the person giving compressions should trade places with the person giving breaths. This is very important, even if you are not tired. Your first several compressions are good and strong but as time passes, you will begin to get tired and your compressions will be less effective, even if you don't feel yourself getting tired. You need a two minute rest so that you can begin again nice and fresh.

Always assess scene safety first. If the scene is not safe, it is reasonable to withhold resuscitation efforts. If you find someone unconscious in the middle of the street and run out to save them and get hit by a car, the situation just got worse and now there are two people needing to be saved.

The American Heart Association now recommends C-A-B sequence instead of A-B-C. When a cardiac arrest happens, there is usually enough oxygen in the blood stream to sustain life, but it must circulate throughout the body. So the most important step to begin with is chest compressions, not rescue breaths. Beginning with chest compressions is the easiest step for bystanders to perform. It will only delay rescue breaths by about 18 seconds.

An AED only detects 2 particular heart rhythms. They are Ventricular Fibrillation or V-Fib and Pulseless Ventricular Tachycardia or Pulseless V-Tach. If the AED detects either of these rhythms it will deliver a shock.

The biggest misconception people have is that when you shock someone, you jump start the heart just like you would jump start a car. This is not true. When the heart is in Ventricular Fibrillation or Pulseless Ventricular Tachycardia the heart is quivering. The heart is getting told to contract too fast, from too many different cells that it can't possibly keep up and just begins to vibrate. Almost like seeing someone on TV having a seizure. The heart just vibrates. The only way to correct all the overstimulation is to stop all of the electricity in the heart. For example: My computer gets a virus. The first thing I want to do is pull the cord from the wall and stop the virus. I don't want to start opening other programs and get them running too. The same goes for V-Fib and Pulseless V-Tach.

The shock stops the heart completely, giving it a chance to start over and hopefully produce a normal organized rhythm. So if defibrillating actually stops the heart, do you see why shocking someone in asystole doesn't make any sense? Why shock someone to stop the heart, when their heart is already stopped.

Always allow the chest to completely recoil when doing compressions. Say there was a small fire, and you had a water bottle full of water. Would it make sense to squeeze tiny amounts out really fast; or, would it make more sense to give the bottle a good squeeze and force out as much water as you can at one time, and repeat? When you compress the chest, it squeezes a small amount of blood out; by letting the chest completely recoil with each compression, more blood is squeezed out with every compression.

RESCUE BREATHING:

For an adult, give 1 breath every 5-6 seconds or 10 - 12 breaths per min.

For a child/infant, give 1 breath every 2 to 3 seconds or 20 to 30 breaths per min. Children run faster than adults, so they must breathe faster too.

If an advanced airway (ETT) is in place regardless of age deliver one breath every 6 seconds. If someone has an advanced airway in place, they will not be conscious. If the person is "sleeping" they will not need to breathe as fast as an adult or child and is the slowest rate of all. Only 1 breath every 6 seconds. This is only 10 breaths per minute. When an advanced airway is used, compressions must be stopped until the tube in placed in the airway. Once it is in place, provide continuous chest compressions without pauses for the breaths. (The tubes are very stiff and firm, slightly flexible. But they are firm enough and long enough to allow oxygen to pass through them effectively while someone is pushing down and compressing the chest.

Opioid overdose can depress a person’s drive to breath and may lead to death. Individuals who are at imminent risk of death from opioids may be given naloxone in pre-hospital settings by trained lay rescuers. Naloxone competes with opioid drugs at opioid receptors, and reverses the effects of the drug. Naloxone has a short half-life in the body—shorter than most opioid drugs of abuse—so multiple administrations may be needed.

Cardiac Arrest in Pregnancy

Do not delay providing chest compressions for a pregnant woman in cardiac arrest. High-quality CPR can increase the mother’s and the infant’s chance of survival. If you do not perform CPR on a pregnant woman when needed, the lives of both the mother and the infant are at risk.

Perform high-quality chest compressions for a pregnant woman in cardiac arrest as you would for any victim of cardiac arrest, but if a second rescuer is available and the abdomen is visibly rounded, have the second rescuer hold the abdomen on the mothers left side (to improve circulation).

Use an AED for a pregnant woman in cardiac arrest as you would for any victim of cardiac arrest. If the woman begins to move, speak, blink, or otherwise react, stop CPR and roll her onto her left side.

CHILD SPECIFIC

A CHILD is considered to be 1 year old, up to puberty. (Not an age, but physical signs of puberty) For lone rescuers, to provide child CPR, use one hand instead of two and compress 2 inches = 5 cm (The same as an adult) or compress 1/3 the depth of the chest. Deliver 30 compressions and 2 breaths.

An INFANT is from birth to 1 year old. For lone rescuers & 2 rescuers, to provide infant CPR, wrap both hands around the infant's chest and place both thumbs on the lower half of the breastbone. If the infant is very little, you may need to place one of your thumbs on top of the other. If the infant is too large, you may also use the heel of one hand. Compress 1 1/2 inches = 4 cm or 1/3 the depth of the chest. Deliver 30 compressions and 2 breaths.

ONE MORE VERY IMPORTANT THING ABOUT PEDIATRIC PATIENTS (CHILDREN & INFANTS)

If the child or infant (UNDER PUBERTY) HAS A PULSE OF 60 or less WITH signs of poor perfusion or signs of cyanosis BEGIN CHEST COMPRESSIONS.

Only perform chest compressions if they also show signs of poor perfusion.

Only perform chest compressions if they also show signs of cyanosis.

Are they blue / cold are their fingers or lips blue, does their color just not look right? Are there any signs the child is not getting enough blood supply and oxygen?)

BEGIN CHEST COMPRESSIONS. DO NOT DELAY.

MAJOR DIFFERENCES IN CHILD AND INFANT CPR:

Over puberty is treated as an adult. Puberty is not defined by age, but instead by physical appearance. For boys: If there is any chest hair, or underarm hair present, they are considered an adult. You cannot use facial hair (either beard or mustache or "peach fuzz") to determine puberty. Some little boys sneak in the bathroom and shave their face like daddy, and they get facial hair before puberty.)

For girls: Look for signs of breast development. If any breast development is present they are considered an adult. So, if you had a 10 year old girl who happens to be pregnant, she has hit puberty and is treated as an adult.

When there are TWO RESCUERS, and the child us UNDER PUBERTY the compression to ventilation ratio changes to 15:2 (Now, 10 cycles is 2 minutes - Check the pulse every two minutes)

For infant compressions with two rescuers, encircle your hands around the infant's chest and provide the compressions using your thumbs over the lower half of the breastbone. Compress at least 1.5 in, 4 cm or 1/3 the depth of the chest.

DIFFERENCES WITH AN AED USED ON CHILDREN AND INFANTS

Some AEDs have Adult and Pediatric pads. Pediatric pads should be used on anyone 8 yrs and under. If pediatric pads are not available you should use the adult pads on an infant or child. For a child, follow the pictures on the pads for proper placement, making sure they do not touch, or overlap.

For an infant, place one pad in the center of the chest, and one pad on the back in the center. If you can, remember "baby sandwich". Pads used on infants under 1 year old are always placed front and back whether you are using pediatric or adult pads.

Adult pads can be used on an infant under 1 year old if you only have adult pads. A burned baby is better than a dead baby, and if a shock is needed it must be delivered.

Never cut the adult pads in half. This will leave a bare metal edge which will allow the shock to arc and shock someone else.

WHEN TO CALL FOR HELP AND WHEN TO START COMPRESSIONS

If an adult, check responsiveness, tap and shout "hey, are you ok ?" Check for breathing: if no breathing activate emergency response system and get an AED Check for a pulse: if no pulse begin chest compressions at a rate of 30:2 For an adult, the compression to ventilation ratio is always 30:2 with 1, or more than 1 rescuer.

If the victim is UNDER PUBERTY, and there are 2 rescuers, begin 15:2 IF they are UNDER PUBERTY and the arrest is witnessed, GET HELP FIRST then return to the child and begin with compressions. Provide 2 minutes of CPR and re-check for a pulse.

When you see a child collapse, (WITNESSED) you know their last breath and last heartbeat was just now. Their blood oxygen level should be pretty high. So get help first. If there are others around, send someone to get help and get and AED.

If you find a child who has collapsed and it was unwitnessed, you have no idea if their blood oxygen level is adequate, so provide 2 minutes of CPR first to get their blood oxygen level back up, and then leave the child to go get help. If there are others around, send someone to get help and get and AED.

IF the arrest is NOT witnessed, Begin 2 minutes of CPR, go get help and an AED and return to the child. Begin cycles of 30 compressions and 2 breaths if you are alone. Check a pulse every 2 minutes.

If there are two rescuers and the child is under puberty, begin cycles of 15 compressions and 2 breaths. Check a pulse every 10 cycles or 2 minutes.

CHOKING

For adults and older children, wrap your hands around the victim's waist and begin abdominal thrusts until the victim becomes unresponsive or until the foreign object is removed.

For an infant, lay them over your forearm supporting the infant's head and neck and begin 5 back slaps (Be sure to cradle the infant face down with head lower than the rest of the body). Turn the infant over and begin 5 chest thrusts (just as you would chest compressions). Continue with 5 back slaps and 5 chest compressions until the object is removed or the infant becomes unconscious.

Once an adult, child or infant becomes unresponsive, do not continue to treat them as a chocking victim. Lay them on a hard flat surface and begin Basic Life Support. Start by tapping and shouting "Hey, Are you Ok ?" Assess breathing, if no breathing or only gasping, activate emergency response and get an AED. Begin chest compressions. Before giving breaths, look in the mouth for the obstructing object. If you can see the object, try to remove it. Do not perform a blind finger sweep.

Attempt to give 2 rescue breaths. If the chest does not rise, reposition the airway and attempt again. If the chest does not rise, begin chest compressions. Between chest compressions and rescue breath attempts, it is hoped that the back and forth motions will move the object one way or the other. Continue as long as you can and just know, that you cannot continue CPR forever. There may be a time when it is just not humanly possible to continue for hours and hours, nor would you want to continue CPR on someone for that length of time. The chances of successfully reviving someone without significant brain damage after an extended amount of time are very slim.

In some circumstances of extreme cold weather or drowning in cold water, CPR should be continued until the person arrives at the hospital. The cold will slow their oxygen demand and slow their heart rate. Depending on the circumstances there is a fair chance of a good outcome if the person is cold. So continue CPR as long as you can. But, remember, you are only human. You cannot expect to perform CPR for hours on end. There will be a time that you cannot humanly continue, and it is ok to stop CPR.

Here are the New 2020 Guideline additions for BLS

Systems of Care: Using Mobile Devices to Summon Rescuers

2020 (New): The use of mobile phone technology by emergency dispatch systems to alert willing bystanders to nearby events that may require CPR or AED use is reasonable.

Adult Chains of Survival

A sixth link, recovery, was added to the in-hospital and out-of-hospital Chains of Survival.

Opioid-Associated Emergency for Healthcare Providers Algorithm

The 2020 Guidelines include an opioid-associated resuscitation emergency algorithm for healthcare providers, shown here. A version for lay rescuers is also included in the Guidelines. This algorithm is for both adults and pediatrics. Changes include:

• There is a clear step now to prevent deterioration, with an initial assessment more clearly laid out.
• Respiratory arrest is more prominently addressed in the beginning, with “Is the person breathing normally?” as an initial decision.

Although naloxone is still recommended for opioid-associated emergencies, it should be considered for preventing deterioration and cardiac arrest, and given during respiratory arrest.

Cardiac Arrest in Pregnancy

Do not delay providing chest compressions for a pregnant woman in cardiac arrest. High-quality CPR can increase the mother’s and the infant’s chance of survival. If you do not perform CPR on a pregnant woman when needed, the lives of both the mother and the infant are at risk.

Perform high-quality chest compressions for a pregnant woman in cardiac arrest as you would for any victim of cardiac arrest. Use an AED for a pregnant woman in cardiac arrest as you would for any victim of cardiac arrest. If the woman begins to move, speak, blink, or otherwise react, stop CPR and roll her onto her left side.

2020 (New): Because pregnant patients are more prone to hypoxia, oxygenation and airway management should be prioritized during resuscitation from cardiac arrest in pregnancy.

2020 (New): Because of potential interference with maternal resuscitation, fetal monitoring should not be undertaken during cardiac arrest in pregnancy.

2020 (New): The AHA recommends targeted temperature management for pregnant women who remain comatose after resuscitation from cardiac arrest.

2020 (New): During targeted temperature management of pregnant patients, it is recommended that the fetus be continuously monitored for bradycardia as a potential complication, and obstetric and neonatal consultation should be sought.

Changes to the Pediatric Assisted Ventilation Rate

Rescue Breathing

2020 (Updated): For infants and children with a pulse but absent or inadequate respiratory effort, it is reasonable to give 1 breath every 2 to 3 seconds (20 to 30 breaths/min).

Ventilation Rate During CPR With an Advanced Airway

2020 (Updated): When performing CPR in infants and children with an advanced airway, it may be reasonable to target a respiratory rate range of 1 breath every 2 to 3 seconds (20 to 30 breaths/min), accounting for age and clinical condition. Rates exceeding these recommendations may compromise hemodynamics.

Real-Time Audiovisual Feedback

2020 (Unchanged/Reaffirmed): It may be reasonable to use audiovisual feedback devices during CPR for real-time optimization of CPR performance.

Debriefing for Rescuers

2020 (New): Debriefings and referral for follow-up for emotional support for lay rescuers, EMS providers, and hospital-based healthcare workers after a cardiac arrest event may be beneficial.

Why: Rescuers may experience anxiety or post-traumatic stress about providing or not providing basic life support. Hospital-based care providers may also experience emotional or psychological effects of caring for a patient with cardiac arrest. Team debriefings may allow a review of team performance (education, quality improvement), as well as recognition of the natural stressors associated with caring for a patient near death.

Control of Life-Threatening Bleeding

2020 (New): A manufactured tourniquet should be used as first-line therapy for life-threatening extremity bleeding and should be placed as soon as possible after the injury.

2020 (New): If a manufactured tourniquet is not immediately available or if a properly applied manufactured tourniquet fails to stop bleeding, direct manual pressure, with the use of a hemostatic dressing if available, should be used to treat life-threatening extremity bleeding.

2020 (New): For individuals with life-threatening external bleeding, direct manual pressure should be applied to achieve initial bleeding cessation for wounds not amenable to a manufactured tourniquet or when a manufactured tourniquet is not immediately available.

2020 (New): If a hemostatic dressing is available, it can be useful as adjunctive therapy to direct manual pressure for the treatment of life-threatening external bleeding.2020 (New): If a manufactured tourniquet is not available and direct manual pressure with or without the use of a hemostatic dressing fails to stop life-threatening bleeding, a first aid provider trained in the use of an improvised tourniquet may consider using one.