BASIC LIFE SUPPORT THEORY

Before reading this, you should watch the 5 minute film found on Youtube titled “ERC BLS WITH

AED”

Objectives

By the end of this session you will have an awareness of:

• Importance of the the Chain of Survival

• Current guidelines for:

Basic Life Support (BLS)

Use of the recovery position

Dealing with a choking victim

• Trust Emergency Equipment (including Automated external defibrillator or AED)

• Trust Documentation in relation to resuscitation

European Resuscitation Council

Please click the link below to watch a short video by the European Resuscitation Council before continuing to the next page

ERC BLS Video

Objectives (continued)

After reading this presentation, you must arrange an appointment via resuscitation training department to be observed delivering BLS and using an AED to be marked as compliant with trust mandatory training. You will be assessed using the following assessment sheet:

NB: by attending the practical assessment you are inferring that you have read and understood all of the content of

this presentation

The steps that contribute to successful outcome after cardiac

arrest form the “chain of survival”. The chain is only as strong as

the weakest link, all links should be strong to give the best

outcomes for patients. The 4 stages of this chain are described

over the next slides.

Stage 1: recognition of deterioration and calling for help

Cardiac arrests in hospital are often preventable. Signs that patients are deteriorating may include signs such as chest pain, acute confusion or drop in level of consciousness and a rise in national early warning score (NEWS) when recording observations. Implementation of NEWS has reduced cardiac arrests by roughly a third as staff are prompted to escalate sick patients early

Calling for help early can prevent further deterioration, which in turn can prevent cardiac arrest and therefore death. Help may include colleagues with a different skill set, doctors or medical emergency team (MET). If recording observations, then NEWS escalation policy MUST be followed

National Early Warning Score (NEWS) When recording observations, this escalation must be followed as a minimum

Once cardiac arrest has been confirmed cardiopulmonary resuscitation (CPR) must be commenced immediately after calling for help. CPR slows down the rate of deterioration of the heart and brain by supplying oxygen. CPR must be performed to a high standard and with minimal interruptions to be effective.

High quality CPR is only equivalent to around a third of the work the body would have done normally, unfortunately CPR is often not of a good standard due to lack of practice, which can lead to nervousness and poor technique.

Very few people will respond to CPR alone, the aim of CPR is to buy time for the victim until further interventions can be made. Chance of survival from cardiac arrest is generally less than 20%.

Stage 2: Early CPR

Defibrillation within 3-5 minutes of collapse can give survival rates as high as 50-70%, however the chances of defibrillation being effective are reduced if CPR is not performed to a high standard

Chance of survival drops by around 10-12% with every passing minute that defibrillation is delayed. This is one of the many reasons why staff should be familiar with where their emergency equipment is, ensure that it is promptly brought to the collapsed patient and always ready for use.

Stage 3: Early defibrillation

While CPR and defibrillation aim to restore a pulse, the ultimate goal is to restore the patient to a stable condition and restore health to the point where they can safely leave hospital with minimal risk of further deterioration.

In terms of BLS, we need to handover the event to the rescuers that have come to give support, the handover tool we use is “SBAR” which is a nationally recognised communication tool:

– S Situation prompting call for help

– B Background including any change prior to collapse

– A Assessment or what is happening now

– R Recommendations (can be given or requested)

For example; “ This patient was seen to collapse and I have confirmed cardiac arrest. They were admitted with chest pain and complained of breathlessness prior to collapse. We have just started CPR and are setting up the defibrillator, please can you take over , what can I do to help?”

Stage 4 : Post-resuscitation care

D R S A B C (approach to confirm cardiac arrest)

• Danger

• Response

• Shout for help

• Airway

• Breathing / Signs of life

• Call 2222 / 999 / 112

Start CPR 30:2

This sequence will now be described in detail

• Check if it is safe for you to approach, are bystanders safe, is the victim safe?

• If you cannot make an environment safe to approach you should wait for further support

• Our biggest hazard in hospital is slips, trips and falls, particularly if there is lots of equipment around the patient – don’t put yourself at risk by being complacent!

Danger

Response

Gently shake the shoulder

Give a simple command eg “open your eyes”

Is the patient responsive?

YES

• Check for injuries

• Reassess

• Get help

NO

• Shout for help, press buzzer

• Continue assessment

Open the Airway • Turn the victim onto their back

• Look in the mouth for foreign body and remove what you safely can (don’t do blind finger sweeps as this can convert a partial airway obstruction to complete). Turn to head to drain secretions or perform suction if immediately available. Leave well fitting dentures in place

• Open the airway with an airway opening manouvre

– head tilt/chin lift (as in picture)

– if cervical spine injury suspected use jaw thrust

Open the Airway – jaw thrust

• Consider jaw thrust when patient has suffered head/neck injury, as keeping the head and neck still minimises the risk of further injury

• Keeping head and neck still, place fingers behind the angle of the jaw and lift upwards

• If this doesn’t open the airway, apply a head tilt gently until airway is open

Is the patient breathing notmally with signs of life (+ / - Pulse)?

YES

• If safe, use recovery position

• Go for help

• Reassess at intervals

Recovery Position • Assists with the drainage of secretions

• Maintains an open airway

• Considered safer position to leave the casualty, in order to gain help

Remember that when a patient is in the recovery position, their airway is safer than if they were on their back, however patients in

the recovery position can also deteriorate to the point of cardiac arrest, so continue to assess

Place arm nearest the

rescuer at a right angle

Place other hand against

the cheek, palm outwards

Lift up behind the knee

furthest away and

push downwards

The patient should roll

over quickly and easily

towards you

To prevent nerve and tissue damage turn the

patient side to side every 30 minutes.

If the patient has significant injuries, place on

the unaffected side first if possible

Is the patient breathing normally with signs of life (+ / - Pulse)?

NO - Call for help:

Call 2222 within trust stating medical emergency followed by your precise location (state paediatric medical emergency if it is a child)

If there is a cardiac arrest or a medical emergency where the airway is compromised (Eg choking, anaphylaxis), on the Royal site only you

should also state anaesthetic team

On external Trust areas state “medical emergency, hospital grounds” followed by location and nearest building

(9)999 or 112 off trust premises to summon ambulance services

• Place heel of the hand on the

lower third of sternum

• Compress chest 100-120 per

minute, or 2 per second

• Depth 5-6 cm

• Deliver 30 compressions

Chest compressions

Start chest compressions • From the side of the victim put your hands on the lower third of the

sternum

• Place heel of hand in centre (crosswise) of chest with other hand on top

• Interlock fingers and pull fingers up ensuring you’re not leaning on the victims ribs.

• Keep your arms straight with shoulders above hands

• Press down on the sternum aiming to depress between 5 and 6 cm, after each compression, release all the pressure on the chest without loosing contact with the sternum.

• Repeat at a rate of 100-120 per min or 2 compressions per second

• Swap rescuers every 2 minutes where possible to maintain quality

Rescue Breaths • After every 30 compressions aim to deliver 2 breaths

• Pinch patient’s nose

• Maintain chin lift

• Ensure a good mouth-to-mouth seal

• Blow steadily (1 sec) into patient’s mouth

• Make chest rise as in normal breathing then repeat a second time

• Remember delivering breaths is safe – there is no recorded cases of Hep B/C or HIV transmission from this intervention

• Breaths are important as they top up the supply of oxygen that compressions push around the body

Ventilation

Use the most appropriate equipment to ventilate

Use pocket mask if available

bag valve mask if trained to do so

Add Oxygen as soon as possible

Consider Insertion of an oropharangeal airway

Rescue mask

• Position the mask over the nose and mouth, pointed end over the nose

• Press the mask to the face to minimise air leaks

• Pull the chin upwards to open the airway

• Blow into the one way valve to make the chest rise and fall as in normal breathing

• Attach oxygen tubing turned up to 15 litres once available

Continue resuscitation at a ratio of 30 compressions to 2 breaths: This ratio stays the same no matter how many rescuers there are Consider 1 minute of CPR before leaving to get help if the victim is a child or have drowned – they are more likely to need oxygen from CPR than a defibrillator

You can stop CPR when:

• Qualified help arrives and takes over

• The patient shows signs of life (if breathing normally consider recovery position)

• You become exhausted

Compression-only CPR

• Should be considered if reluctance or inability to perform mouth-to-mouth ventilation and no equipment available

• Chest compressions alone are better than no CPR

• If possible combine with head tilt, there is some evidence that shows this will generate artificial breathing to a small degree

Neck breathers

• If a patient breathes through a stoma to their neck breaths should be delivered through this stoma rather than their mouth (upper airway may not be connected)

• Cover/close nose and mouth

• Don’t do head tilt chin lift

• Deliver rescue breaths via stoma aiming to make the chest rise and fall as in normal breathing

• Use a neck breather mask when available

(found in airway drawer on emergency trolley)

How to deal with a choking victim: Initial assessment

• Choking may be recognised by coughing, colour changes, agitation, pointing to the throat, or the victim may say “I’m choking!”

• Encourage coughing until signs of cyanosis or cough is ineffective/silent (when the victim is coughing, they are the best person to dislodge the obstruction!). Once we recognise either of these signs, we should intervene

First choking manouvre is to deliver up to 5

back blows. Position the victim upright and

leaning forwards to deliver a sharp blow

between the shoulder blades, assessing for

effectiveness after each blow

If not effective deliver up to 5

abdominal thrusts. Make a fist in front

of the abdomen pulling inwards and

upward sharply, assessing for

effectiveness

Alternate between both choking manouvres until airway is cleared

If the victim is pregnant or <1 yr perform chst thrusts instead of

abdominal thrusts

Patient loses consciousness

If not already done, call 2222 or 999 / 112

Then commence CPR at a ratio of 30:2

Until patient starts to breathe normally

In Summary

• Danger

• Response

• Shout for Help

• Airway

• Breathing / Signs of Life

• Call 2222 or 999 / 112

Start CPR 30:2

Trust Documentation

Reporting

Electronic incident report (DATIX) should be completed for EVERY call to 2222 summoning MET including:

• MET calls for both deteriorating patients and cardiac arrest

• Call triggered by raised NEWS

• False alarms

It is everybody’s responsibility to complete DATIX which should be completed as near to the time of the event as possible

Transfer policy

When moving patients around

the trust, this should be planned

to ensure a safe journey for the

patient. This should include

ensuring the receiving area is

ready before you set off and an

assessment of what equipment

and personnel are necessary. If

you don’t think you have enough

resources to safely move the

patient, this should be escalated

“Do not attempt Cardiopulmonary Resuscitation” (DNACPR)

• Many in-hospital cardiac arrests occur following a period of decline due to co-morbidities

• It is vital to recognise this and make pro-active decisions

• Making a DNACPR decision allows a person to die with dignity (inappropriate CPR can prolong death rather than extending life)

• Patients can remain for active treatment and have a DNACPR decision (do not resuscitate does not mean do not treat)

• Providing active treatment is not a reason not to consider and document what to do in event of cardiac arrest

• You should ensure you know the resuscitation status of your patients, and if unsure, ask. If a patient arrests and there is lack of clarity around resuscitation status you should start CPR

Who do we discuss DNACPR with?

• All patients with capacity

must be consulted unless it

is believed that the

discussion is likely to cause

harm or the patient indicates

that they do not want to

participate.

• Document this on the red

card

• The decision is a clinical one

based on assessment and

consideration of the patient’s

best interests The Guardian, 17 June 2014

RLBUHT DNACPR document

• At present we are using this red

card system to communicate

resuscitation status

• Can only be completed by senior

doctors, but may be updated by a

junior doctor

• Expiry date should be checked at

the beginning of every shift and this

should be communicated with all

staff who come into contact with the

patient

• This document is only valid for one

hospital admission and is voided by

discharge from the trust

• uDNACPR is the document used in

community to communicate that a

patient is not for CPR

• If a patient is admitted to our trust

with this document, doctors in the

admission areas will complete the

trust DNACPR to acknowledge this

decision is in place.

• Consultants can discharge a patient

into community with this order

completed if appropriate to do so

Picture 679 from desktop

Emergency equipment

Bottom door must be opened fully before top drawers will unlock

Daily checklist (front)

• Daily checklist must

completed at least once

every 24 hours, this will be

audited and fed back to

trust board

• Yes or no should be

completed for each box as

appropriate

• Four weeks of records only

should be kept on the

trolley

Daily checklist (back)

If you have to record no for

any part of the daily

checklist your actions must

be completed on the

reverse of the checklist. Any

issues you cannot rectify

should be escalated

Weekly checklist:

A full trolley check should

be made:

• Every 7 days as a

minimum

• If the trolley has

been`opened for any

reason including training

• If on a daily check it is

noted that the last

recorded security seal

number doesn’t match

the one on the trolley

Each 24 hours as a minimum the

trolley must have a daily check. This is

to ensure that the trolley is clean and

servicable, the defibrillator passes it’s

test, the security seal matches the last

recorded number, and the following

items are available and in date:

• 1x Oxygen cylinder at least 3/4 full

• 1x Self- inflating bag (Ambu) with

reservoir, Oxygen tubing

• 1x pocket mask - Disposable

• 1x box of gloves (medium)

• 1x sharps container

• 1x Multifunction defibrillator pads

NB test blocks MUST be removed from

defibrillator cable after testing

Top of trolley

Top of trolley: portable suction machine (runs on mains or

battery if charged). Suction is part of emergency equipment

and must also be checked on a daily basis

Top drawer: equipment to take bloods, cannulate etc

(checked each time seal is broken or every 7 days)

• 6x Sodium Chloride 0.9% flush – 10

ml pre-drawn syringes

• 4x |Safety Needles -

(blue/green/white/blunt)

• 2x Each size Ported B-Braun

Venflons - (14g - orange, 16g – grey,

18g – green)

NB NO OTHER TYPE TO BE

ADDED

• 2x 3-Way taps

• 2x Gauze swabs

• 1x Tape

• 4 x IV dressings

• 10x alcohol swabs

• 2x disposable tourniquets

• 2x Cling bandages

• 2x Syringes - (5, 10, 20ml)

• 2x Arterial blood gas syringes

Second drawer: equipment for airway and breathing support

(checked each time seal is broken or every 7 days)

• 1x Adult non-rebreather O2 mask

• 1x Guedal airways - size 2, 3 & 4

• 1x Nasopharangeal airway size 6mm

or 28F + 7mm or 32F

• 4x sachets Lubricant

• 1x Resuscitation mask for neck breathers

with

one way valve

• 1x Cuffed endotracheal tubes - size 6, 7, 8 &

9 (All tubes low pressure, uncut and sealed)

• 1x Catheter Mount

• 1x Mac 3 Laryngoscope single use.

• 1X mac 4 Laryngoscope single use

• 1x intubation stylet - 1x Bandage/tape to

secure

• 1x Stethoscope

• 1x Magills forceps – Disposable

• 1x Bandage/tape to secure ET tube

• 1x Adult Yankauer

• 1x strong scissors1

• x Bougie

• 1x 20ml Syringe

• 1x 10,12,14,16 F, Fine Bore Suction Catheter

BGH only

• 1x LMAs size - 3,4 & 5

• 1x 50ml syringe

Third drawer: Fluids and giving sets

(checked each time seal is broken or every 7 days)

• 2x Blood giving set

• 1x IV giving set

• 1x 500ml Glucose 10%

• 1x 1000ml Hartmans

• 1x 1000ml Sodium

Chloride 0.9%

• 1x 500ml Gelofusine

Bottom drawer

(checked each time seal is broken or every 7 days)

• 2x packs of ECG

electrodes-(3 in

each pack)

• 2x Leadercath

central line (14 +

16G)

• 1x Emergency

drug box - in date

• 1x Spare ECG roll

• 1x Multifunction

pads in date

BLS with AED algorithm (as seen in ERC film)

Use of AED

Use of AED/PAD:

• Turn machine on and follow voice

prompts • Pads must be placed on the clean, bare

dry chest of victim avoiding jewellery/implanted devices by 8-10cm

• Minimise unnecessary interruptions to

CPR • If prompted to press shock button,

ensure nobody is touching the patient and immediately return to CPR

• NB It is not expected that staff use the manual mode of defibrillators unless trained to do so (ILS or ALS trained)

Additional Learning

For additional information and learning please click on the link below to watch the Resuscitation Council Life Saver video

http://www.life-saver.org.uk/

And visit www.resus.org.uk

For any other training or enquiries contact;

Department of Resuscitation Training

Extension 2045

Email resus.courses@rlbuht.nhs.uk