Cardiology and Resuscitation Study Guide for the EMT Test

Resuscitation

What is BLS?

Basic Life Support (BLS) includes the concept of recognizing and providing high-quality care for someone in need of CPR or someone in another life-threatening cardiovascular situation. There are standard scientific best practices established that are related to the actions and sequence of the steps of care.

Elements of BLS

Basic Life Support (BLS) consists of techniques aimed at sustaining life in an emergency relating to the airway, respiratory function, or cardiac arrest. The basic treatment elements of chest compressions and assisted breaths focus on airway (obstruction), breathing (respiratory arrest), and circulation (cardiac arrest or bleeding). In 2010, the American Heart Association updated CPR guidelines from the “ABC” (airway, breathing, chest compressions) to “CAB” (chest compressions, airway, breathing) model. This is because data has shown that those receiving little delay in chest compressions (i.e., chest compressions done first) have better outcomes.

The elements in Advanced Life Support (ALS) build on BLS concepts, but differ in that they also include monitoring, IV fluid, advanced skills, and/or medication administration.

Determining the Need for BLS

To determine if someone is in need of BLS that includes CPR, the EMT will assess for key elements. Establish that the patient is breathing and has a patent airway. Ensure there is adequate circulation via pulse palpation and no signs of bleeding.

Terms/Concepts to Know: basic elements of CPR, CAB, ABCs

CPR

Cardiopulmonary resuscitation is used to assist a person who presents with absent pulses and respirations. This technique was developed in the 1960s and has evolved to provide both healthcare and laypersons with ongoing current knowledge to assist in a cardiopulmonary or respiratory crisis.

Purpose of CPR

The main goal of CPR is to establish spontaneous breathing and circulation after the cessation of these functions. The purpose of CPR is to keep oxygenated blood flowing to the brain and heart. This happens through the use of artificial maneuvers by someone trained in them.

Terms/Concepts to Know: five links in the chain of survival

Steps in CPR

There are seven critical steps in CPR. These steps are:

Take standard precautions and establish unresponsiveness.
Position the patient supine on a flat surface.
Assess breathing and pulse.
Perform chest compressions if a pulse and breathing are absent, until an AED is available.
Open the airway.
Give two ventilations while observing for chest rise.
Continue cycles of 30 chest compressions and two ventilations.

Terms/Concepts to Know: one-rescuer CPR, two-rescuer CPR

CPR Guidelines

CPR is not an absolute treatment for every situation in which someone is unresponsive. Before beginning CPR, always assess the airway and pulse. Do not perform compressions on an unresponsive person who has a pulse. Do not attempt to provide artificial ventilations if the person has an open airway with adequate respirations.

When Not to Start CPR

There are certain scenarios where CPR is not an appropriate intervention. If a person is not breathing but has a pulse, CPR should not be done, though appropriate respiratory support should be given. CPR should be withheld on patients with DNR orders, patients with rigor mortis, or at the base physician’s order.

Terms/Concepts to Know: non-survivable injuries, rigor and livor mortis, DNR orders

When to Stop CPR

When CPR is initiated, the intent is to continue until the patient wakes up, expires, or more advanced interventions can be done. There are standard criteria for the cessation of CPR that can be remembered by the acronym STOP. They are:

S: Starts breathing

T: Transfer of care

O: Out of strength

P: Physician’s order

Terms/Concepts to Know: STOP mnemonic

Interrupting CPR

CPR is intended to be a life-saving intervention. When CPR begins, interruption should be very minimal. Often, the absence of ALS on the scene will create the need for CPR to be performed in transport. The emergency team should perform continuous CPR except for minimal necessary interruptions, such as lifting the patient for transport. Interruptions to chest compressions should be no more than 10 seconds.

Terms/Concepts to Know: chest compression fraction

Patient Care

Care of the patient requires more than performing the technical maneuvers or use of equipment. When a patient is in an emergency or crisis situation, there are multiple things to consider, such as what preceded the event, is the scene safe, does the patient have other injuries, are there friends or family present, and what do witnesses know? The answers to these questions will help to frame a plan of care.

Positioning

A firm, flat surface and a supine position provide the best way to assess the patient and perform CPR. If possible, you should work to ensure enough space for two rescuers and equipment before the procedure is initiated. Use the recovery position for patients with no spinal injuries who are breathing on their own and may have decreased loc.

Terms/Concepts to Know: supine, prone, logroll, recovery position

Breathing and Pulse Check

Before beginning CPR on a patient who appears unresponsive, a basic CPR needs assessment should be done. Try to arouse the patient, and take 10 seconds to look, listen, and feel for breathing and pulses.

Terms/Concepts to Know: carotid artery location, how to palpate carotid pulse, how to assess for breathing and pulse

Chest Compressions

The initiation of chest compressions is important for quality CPR in patients without a pulse. The key to quality compressions is an appropriate technique that includes correct hand positioning and depth of compressions, depending on the age of the patient. In adults, the rescuer should kneel next to the patient, and the fingers should be laced together, one on top of the other, and placed over the tip of the patient’s breastbone. Compressions should be given at a rate of 100 a minute, at a depth of at least 2 inches. Two breaths should be given after 30 compressions, regardless of whether there are one or two rescuers present.

Terms/Concepts to Know: depth required for adult compressions, CPR hand and arm position for compressions

CPR in Children and Infants

In most cases, a pediatric patient does not have a cardiac arrest unless there is cardiac history or a respiratory condition that leads to cardiopulmonary complications. If CPR is initiated, appropriate breaths and hand placement is essential.

In children ages one to puberty, the rescuer should place one or two hands in the center of the chest, between the nipple line. Compression depth should be at least 2 inches and compressions should be delivered at a rate of 100 per minute. If one rescuer is present, the compression-ventilation ratio is 30:2, and for two rescuers, the rate is 15:2.

In infants one year or less, the compression rate of 100 per minute is the same, but the depth should be reduced to 1 1/2 inches. Hand placement and CPR ratios are different depending on how many rescuers are present. If only one rescuer is available, the rescuer should stay at the patient’s side, using two fingers to compress the chest just below the patient’s nipple line. The compression-ventilation ratio for single rescuer infant CPR is 30:2. In two-person infant CPR, one rescuer should stay at the head and the other at the feet. The rescuer responsible for compressions should use both hands to encircle the chest, delivering 15 compressions for every two breaths.

Terms/Concepts to Know: ischemia, hypoxia, standard position, infant and child compression depth

Airway

Upper airway obstructions are very common in children. Small children tend to put things in their mouths that are not necessarily edible. These objects, as well as poorly chewed food items, can lodge in the airway and cause obstruction.

Open the Airway

The process to open the airway of all ages involves the same maneuver. The head tilt-chin lift maneuver is used for all patients who are without risk of spinal injury. If a spinal injury is suspected, the use of the jaw-thrust maneuver is recommended to decrease the risk of spinal injury.

Terms/Concepts to Know: open airway maneuvers

Foreign Object Airway Obstruction

Airway and breathing are two of the key ingredients for CPR. Airway obstruction can be caused by a foreign body that has been aspirated or an object that cannot pass through the airway. Check for obstructions, including the tongue, and use the recommended maneuver to attempt to open the airway.

Recognizing: If a foreign body is present in the airway, the body responds by coughing or gagging. If the object is large enough to cause a complete obstruction, the victim may make a high-pitched gasping or wheezing sound, or may not be able to make a sound at all. A choking victim may make the universal sign for choking by placing one or both hands around their neck and may also exhibit bluish lips or skin.

Technique

Abdominal thrusts, more commonly known as the Heimlich maneuver, are considered the gold standard in removing foreign objects from the airway in children and adults. In this technique, the rescuer stands behind the victim, encircling his/her abdomen with both arms. The rescuer makes a fist and places it below the ribcage and above the navel. The other hand grasps the fist for support, and a quick, upward thrust is employed. The maneuver should be continued until the object is expelled or until the victim becomes unconscious, after which time CPR should be performed.

A chest thrust is used when an abdominal thrust can’t be, such as in morbidly obese patients, patients who are lying down, and pregnant women. In this scenario, the fist is placed higher on the victim’s body, in the middle of the sternum as opposed to the lower part. If the victim is lying down, kneel at the patient’s side and use the heel of the hand to deliver upward thrusts to the middle of the sternum.

Removing in adults: To remove a foreign body from an adult, use the abdominal thrust maneuver. If the patient is or becomes unresponsive, the chest thrust maneuver should be used after observation to manually remove any visible objects. With pregnant women, use the chest instead of abdominal thrusts to accommodate their larger abdomen.
Removing in children:To remove a foreign body from a responsive child over the age of one, use the abdominal thrust maneuver. If the child is or becomes unresponsive, the use of chest thrust maneuver is recommended. Observe to see if the object is visible for manual removal before any other action is taken.
Removing in infants: Infants and children under one year have fragile organs and abdominal thrusts are not appropriate to use on them. Use the back slap chest thrust maneuver for responsive patients. If the patient is or becomes unresponsive, check the mouth for visible objects and remove. Follow infant/child CPR recommendations.

Terms/Concepts to Know: stridor, recognizing signs of airway obstruction, abdominal thrust, chest thrust, back slap maneuvers

Artificial Ventilation

A number of devices, with or without oxygen, that provide artificial ventilation are available. Use the one-way valve pocket mask or BVM as a standard device to ventilate patients by mouth or for patients with a stoma.

Terms/Concepts to Know: ventilation, hyperventilation, stoma ventilation, gastric distention

Circulation Techniques and Devices

CPR, since its inception in the 1960s, has incorporated a combination of manual chest compressions and ventilation with some best practice variations. Currently, there are devices being studied and introduced to this field that may assist with circulation and compressions. These devices may impact the quality of compressions that can be affected when a rescuer becomes fatigued.

Active Compression-Decompression CPR

This is a technique that uses a suction cup-type device to compress the chest and then pull the chest back to the normal or extended position.

Terms/Concepts to Know: active compression-decompression device indications and usage

Impedance Threshold Device

This device functions to create an increased intrathoracic pressure to help blood flow to the heart. It is recommended as an adjunct to other circulatory devices and is not for use with manual CPR.

Terms/Concepts to Know: how the ITD device is used, reasons for usage and limitations

Mechanical Piston Device

This device comprises an electric or gas-powered plunger mounted on a backboard. It is built in a way to position the patient in the supine position. The plunger is positioned over the thoracic area and performs compressions. This device may be used to assist in the field where there is a need for the team to perform other duties.

Terms/Concepts to Know: mechanical piston device function

Load-Distributing Band CPR or Vest CPR

This device comprises a constricting band and a backboard. It can deliver thoracic compressions pneumatically or electrically. The patient is placed on the board in a supine position with the band around the chest area circumference and the compressor over the thorax. This device is used in the field to allow the emergency team to tend to other tasks.

Terms/Concepts to Know: LDB function