Patient Treatment and Transport Study Guide for the EMT Test

Cardiovascular and Circulatory Management: Part 1

Cardiovascular and circulatory management focuses on maintaining adequate blood flow and oxygen delivery to the body’s tissues, which is essential for life. EMTs assess the patient’s circulation by checking the patient’s pulse, skin color, temperature, and blood pressure; they also provide intervention as necessary. Management may include bleeding control, fluid administration if allowed, vital sign monitoring, and rapid transport provision.

Cardiac Arrest Care

According to the American Heart Association, “Each year, more than 350,000 cardiac arrests occur outside of the hospital in the United States.” Cardiac arrest is described as the complete cessation of the heart’s electrical and/or mechanical system to function. This is not the same as a heart attack, which is caused by a blockage that prevents blood flow to the heart.

Preparation

Safe and rapid response for a patient experiencing cardiac arrest is critical to survival. Prepare to provide care for the patient by assigning roles to team members and assessing the scene, MOI, and environment. Also, observe any additional or potential injuries and environmental factors that could impact safe care.

Here are some concepts to know:

heart attack—also known as myocardial infarction; occurs when blood flow to a portion of the heart muscle is blocked, usually by a blood clot, causing tissue damage
cardiac arrest—occurs when the heart suddenly stops pumping blood effectively, leading to a loss of circulation and consciousness

Resuscitation and Basic Life Support (BLS)

BLS includes recognizing and providing high-quality care for someone in need of cardiopulmonary resuscitation (CPR) or for someone in another life-threatening cardiovascular situation. There are established scientific best practices related to the actions and sequence of steps in 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 the “CAB” (chest compressions, airway, breathing) model. This is because data have shown that those receiving little delay in chest compressions (i.e., chest compressions done first) have better outcomes.

The elements of Advanced Life Support (ALS) build on BLS concepts but also include monitoring, IV fluids, advanced skills, and/or medication administration.

Determining the Need for BLS

To determine whether someone needs BLS, including CPR, the EMT will assess key elements. Establish that the patient is breathing and has a patent airway. Ensure there is adequate circulation via pulse palpation and there are no signs of bleeding.

Here are some concepts to know:

basic elements of CPR—chest compressions (to manually circulate blood), rescue breaths (to provide oxygen to the lungs), and use of the AED (to restore normal heart rhythm)
CAB—compressions, airway, breathing; the sequence of events in the order they should occur to provide proper resuscitative efforts
ABCs—airway, breathing, circulation; key concepts that must be evaluated, assessed, and managed by the EMT with all patients

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 professionals and laypersons with up-to-date knowledge to assist in a cardiopulmonary or respiratory crisis.

Purpose of CPR

The main goal of CPR is to restore spontaneous breathing and circulation after their cessation. 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.

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.

Here are some concepts to know:

one-rescuer CPR—This is performed when only a single provider is available to provide care during cardiac arrest. The rescuer performs 30 chest compressions and rescue breathing in a continuous cycle.
two-rescuer CPR—This is performed when two providers are available to care for a patient in cardiac arrest, allowing more efficient and effective resuscitation. One rescuer performs chest compressions while the other manages the airway and provides rescue breaths in cycles of 30 compressions to two breaths for adults. Providers should switch roles every two minutes or when fatigued.
pit crew approach to CPR—a coordinated resuscitation method that uses a tea of at least four providers, with each team member assigned a specific task during cardiac arrest care to help minimize interruptions in 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.

Here are some concepts to know:

non-survivable injuries—These are traumatic conditions so severe that survival is extremely unlikely, even with immediate medical intervention.
rigor and livor mortis—These are postmortem changes that help the EMT identify signs of death. Rigor mortis refers to the stiffening of the muscles that occurs several hours after death. Livor mortis is the pooling and discoloration of blood in the lowest parts of the body.
DNR orders—DNR stands for do not resuscitate. Orders for this constitute a legal document indicating that a patient does not wish to receive CPR or advanced cardiac life support (ACLS) in the event of cardiac arrest.

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

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.

Here are some concepts to know:

chest compression fraction—This is the percentage of time during cardiac arrest that chest compressions are actively being performed. Higher CCF means fewer interruptions during compressions, improved blood flow, and increased chances of survival.
full chest recoil—During CPR, allow the chest to return completely to its normal position between compressions. Full recoil helps the blood return to the heart so the heart chambers can refill before the next compression.

Patient Care

Care of the patient requires more than performing the technical maneuvers or using equipment. When a patient is in an emergency or crisis, there are multiple things to consider, such as what preceded the event, whether the scene is safe, whether the patient has other injuries, whether there are friends or family present, and what witnesses know. Answers to questions about these things will help 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. 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.

Here are some concepts to know:

supine—lying flat on back, face up
prone—lying flat on stomach, face down
logroll—technique used to safely move or position a patient while maintaining spinal alignment
recovery position—safe, lateral position used for unconscious patients who are breathing adequately but are at risk of airway obstruction

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.

Here are some concepts to know:

carotid artery location—These are major blood vessels located on either side of the neck, supplying blood to the brain, neck, and face.
how to palpate carotid pulse—Place the index and middle finger on either side of the patient’s trachea, in the groove between the trachea and sternocleidomastoid muscle, and apply pressure gently.
how to assess for breathing and pulse—Look, listen, and feel for normal breathing for no more than 10 seconds by observing the chest, listening for breath sounds, and feeling for air movement while simultaneously palpating a carotid 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, lace their fingers together, and place them over the tip of the patient’s breastbone. Compressions should be given at a rate of 100 per 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.

Here are some concepts to know:

depth required for adult compressions—This is at least 2 inches or one-third the depth of the chest.
CPR hand and arm position for compressions—The heel of the hand should be placed on the breast bone in the center of the nipple line with the other hand overlapping and fingers interlocked, arms should be straight.
chest compression placement—Place the hands over the lower half of the sternum. Avoid pressing directly on the xiphoid process, the small structure at the end of the sternum because it can be injured during 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 are 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; if two rescuers are present, the ratio 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 vary depending on the number of rescuers 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.

Here are some concepts to know:

ischemia—reduction or complete blockage of blood flow to a part of the body, often resulting in oxygen deprivation to tissues
hypoxia—a condition in which the body or specific tissue does not receive enough oxygen to function properly
standard position—supine position, when the patient lies flat on their back with arms at their sides
infant and child compression depth—infant depth should be 1.5 inches, and children should be 2 inches (same as adults)
infant pulse check—For an infant, the brachial pulse is usually checked first. The brachial artery is located on the inside of the upper arm between the elbow and shoulder.
pediatric bradycardia— In children, a slow heart rate is commonly caused by inadequate oxygenation. Hypoxia can progress to bradycardia, poor perfusion, and cardiac arrest if it is not corrected.

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.

Foreign Object Airway Obstruction

Airway and breathing are two key components of 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.
removal techniques:
- 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.

Different-aged patients require special removal strategies:

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. For pregnant women, use chest thrusts 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 the chest thrust maneuver is recommended. Observe whether 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 them. Follow infant/child CPR recommendations.

Here are some concepts to know:

stridor—high-pitched, harsh, crowing sound heard while auscultating breathing. Indicates upper airway obstruction
recognizing signs of airway obstruction—inability to speak, stridor, gasping, use of accessory muscles, universal choking sign, cyanosis, drooling, and lack of air movement may all be indicative of airway obstruction
**abdominal thrust—the Heimlich maneuver, a technique used to relieve a severe foreign body airway obstruction in a responsive adult or child; performed by delivering quick, upward thrusts into the patient’s upper abdomen, just above the navel, to create a rapid increase in pressure, thus expelling the object
chest thrust—alternative technique used to relieve a severe foreign body airway obstruction when abdominal thrusts cannot be performed (pregnancy, obesity); the same maneuver as an abdominal thrust, but instead of placing the fist over the lower half of the sternum, place it over the middle part of the sternum
back slap maneuvers—technique used to relieve severe foreign body airway obstruction; mainly in infants; consists of delivery of firm, controlled blows with the heel of the hand between the patient’s shoulder blades

Artificial Ventilation

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

Here are some concepts to know:

ventilation—the process of moving air in and out of the lungs to facilitate gas exchange
hyperventilation—faster and/or deeper breathing than normal, causing excessive elimination of carbon dioxide
stoma ventilation—process of providing ventilations through a surgically created opening in the neck that connects directly to the trachea
gastric distention—inflation of the stomach with air, usually caused by improper or forceful ventilation during rescue breathing or BVM use

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.

Here is concept to know:

active compression-decompression device indications and usage—This type of device is utilized during cardiac arrest when CPR is required; it is most beneficial when standard CPR is ineffective or when enhanced circulation is desired. The device is used to enhance chest recoil, increase negative intrathoracic pressure, and improve venous return and cardiac output. It does this by being properly positioned on the lower half of the sternum with the patient on a firm surface. The device should be pushed straight down to the recommended compression depth, then pulled upward until the chest returns to its natural resting position.

Impedance Threshold Device (ITD)

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.

Here are some concepts to know:

how the ITD device is used—The ITD attaches to a BVM, endotracheal tube, or advanced airway for use.
reasons for usage and limitations—The ITD is used to limit air entry into the lungs during chest recoil, creating negative intrathoracic pressure, thus improving venous return to the heart and enhancing circulation during CPR. Limitations include decreased effectiveness with hyperventilation, potential interference with ventilation, and is beneficial only in cardiac arrest; its use is not intended for spontaneous breathing.

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.

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.

Patient Treatment and Transport Study Guide for the EMT Test

Cardiovascular and Circulatory Management: Part 1

Cardiac Arrest Care

Preparation

Resuscitation and Basic Life Support (BLS)

Elements of BLS

Determining the Need for BLS

CPR

Purpose of CPR

Steps in CPR

CPR Guidelines

When Not to Start CPR

When to Stop CPR

Interrupting CPR

Patient Care

Positioning

Breathing and Pulse Check

Chest Compressions

CPR in Children and Infants

Airway

Open the Airway

Foreign Object Airway Obstruction

Artificial Ventilation

Circulation Techniques and Devices

Active Compression-Decompression CPR

Impedance Threshold Device (ITD)

Mechanical Piston Device

Load-Distributing Band CPR or Vest CPR

Other Resuscitation Topics

Special Circumstances