BLS – ACLS

ROLI JOSEPH Z. MONTA, RN

BLS, ACLS, Trauma, HazMat Certified
CPR
 Age Definition

Adults Adolescents (ie, after the onset of puberty)and older

Children 1 year of age to puberty

Infants Less than 1 year of age (excluding newly born infants in DR)

Age Definitions
 Start compression within 10 seconds of recognition of cardiac arrest
Push hard and fast: compress at a rate of 100 to 120/min with a depth of:
- At least 5 cm for adults
- At least 1/3 of the depth of the chest, about 5 cm , for children
- At least 1/3 the depth of the chest, about 4 cm, for infants
Allow complete chest recoil after each compression
High Quality CPR Minimize interruptions in compressions (try to limit interruptions to less than
10 seconds)
Give effective breaths that make the chest rise
Avoid excessive ventilation.

Compression depth greater than 6cm in adults may cause injuries.

 Sudden Cardiac Arrest Heart Attack

What it is? - Abnormal rhythm and can’t - Blood flow to part of the heart
pump blood is blocked

- The heart quiver so it can no - Clot forms in a blood vessel

longer pump blood to the carrying oxygenated blood to
brain, lungs, and other the heart muscle. If the blocked
Cardiac Arrest or organs vessel is not reopened quickly,
the muscle normally nourished
Heart Attack? by that muscle begins to die.

- a “rhythm” problem - “clot” problem

 Sudden Cardiac Arrest Heart Attack
What happens? - Death occurs within - The longer the person with a
minutes if the victim does heart attack goes without
not receive immediate treatment, the greater the
lifesaving treatment. possible damage to the heart
muscle.
- Signs of heart attack may
appear immediately or last
Cardiac Arrest or weeks or longer, and may
include
Heart Attack? • Severe discomfort in the chest
or other areas of the upper
body
• SOB
• Cold sweats
• Nausea/vomiting
Occasionally, the damaged heart
muscle triggers an abnormal
rhythm that can lead to sudden
cardiac arrest.
 Sudden Cardiac Arrest Heart Attack
What happens? Occasionally, the damaged heart
muscle triggers an abnormal rhythm
that can lead to sudden cardiac arrest.

Heart attack symptoms in women can

be different from those in men, and
women may be more likely to
Cardiac Arrest or experience
• Pain in the jaw, arms, back or neck.
Heart Attack? • Light-headedness
• Nausea/vomiting
 What is the link? Most heart attacks do not lead to sudden cardiac
arrest, though a small percentage of people with a
heart attack will develop sudden cardiac arrest.

But when sudden cardiac arrest occurs, heart attack is

a common cause.

Other conditions may also change the heart’s rhythm

Cardiac Arrest and lead to cardiac arrest.

or Heart
Attack?
 Basic Framework for CPR
• Hands-Only CPR. A single rescuer with little training and limited
equipment who witnesses a cardiac arrest in a middle-aged man might
provide only chest compressions until help arrives.
• 30:2 CPR
• Teamwork. Perform multi-rescuer coordinated CPR.
BLS for Adults With a team approach, several lifesaving actions are performed at the
same time
Chest compressions
Gives breath with a bag-mask device
Defibrillator
Hospital setting ?
 Main Components of CPR:
• Chest compression
BLS for Adults • Airway
• Breathing
 Adult Rescuer BLS Sequence:
I. Verify Scene Safety; Check for Responsiveness
1. Verify that the scene is safe for you and the victim. You do not want to
become a victim yourself.
2. Check for responsiveness. Tap the victim’s shoulder and shout, “Are you
OK?”
BLS for Adults 3. If the victim is not responsive, shout for nearby help.
4. Activate the emergency response system as appropriate in your setting.
5. If you are alone, get the AED/defibrillator and emergency equipment. If
someone else is available, send that person to get it.
 Emergency Response System
• Hospital: Activating a specific hospital code, medical emergency team or
rapid response team
BLS for Adults • Prehospital: Activating EMS, paramedics, medic units, advanced life
support or calling for back-up
• Workplace/Facility: Calling your local emergency number or activating
specific workplace emergency response protocols
 II. Assess for Breathing and Pulse
Breathing
Scan the victim’s chest for rise and fall for no more than 10 seconds:
• If the victim is breathing, monitor the victim until additional help arrives
• If the victim is not breathing or is only gasping, this is not considered normal
breathing and is a sign of cardiac arrest
Check Pulse
BLS for Adults To perform a pulse check in an adult, palpate a carotid pulse
If you do not definitely feel a pulse within 10 seconds, begin high-quality CPR,
starting with chest compressions.
In all scenarios, by the time cardiac arrest is identified, the emergency
response team or back-up must be activated and someone must be sent to
retrieve the AED and emergency equipment.
 Agonal Gasps are not normal breathing.
Agonal gasps may be present in the first minutes after sudden cardiac arrest.
A person who gasps usually looks like he is drawing air in very quickly. The
mouth may be open and the jaw, head, or neck may move with gasps.
BLS for Adults Gasps may appear forceful or weak. Some time may pass between gasps
because they usually happen at a slow rate. The gasp may sound like a snort,
snore, or groan.
Gasping is not normal breathing. It s a sign of cardiac arrest.
 III. Locating the Carotid Pulse
1. Locate the trachea, using 2 or 3 fingers
2. Slide these 2 or 3 fingers into the groove between the trachea and the
BLS for Adults muscle at the side of the neck, where you can feel the carotid pulse
3. Feel for a pulse for at least 5 but no more than 10 seconds. If you do not
definitely feel a pulse, begin CPR, starting with chest compressions.
 III a,b Determine Next Actions
If Then

If the victim is breathing Monitor the victim.

normally and a pulse is present

If the victim is not breathing Provide rescue breathing:

normally but a pulse is present • Confirm that the emergency response system has
been activated
BLS for Adults • Continue rescue breathing, and check pulse about
every 2 minutes. Be ready to perform high-quality
CPR if you do not feel a pulse.
• If opioid use is suspected, consider naloxone if
available and follow your local protocols

If the victim is not breathing Begin high-quality CPR

normally or is only gasping and
has no pulse
 IV. Begin High-Quality CPR, Starting with Chest Compressions
Step Action

1 Position yourself at the victim’s side

2 Make sure the victim is lying face-up on a firm, flat surface. If the victim is lying
facedown, carefully roll him face-up. If you suspect the victim has a head or neck
injury, try to keep the head, neck and torso in a line when rolling the victim to a
face-up position.

3 Position your hands and body to perform chest compressions:

• Put the heel of one hand in the center of the victims chest, on the lower half of
BLS for Adults the breastbone (sternum)
• Put the heel of your other hand on top of the first hand
• Straighten your arms and position your shoulders directly over your hands

4 Give chest compressions at a rate of 100 to 120/min.

5 Press down at least 5 cm (1 inch) with each compression. For each chest
compression, make sure you push straight down on the victim’s breastbone
6 At the end of each compression, make sure you allow the chest recoil completely
7 Minimize interruptions of chest compressions
 Alternate Technique for Chest Compressions
BLS for Adults Put one hand on the breastbone to push on the chest.
This technique may be helpful for rescuers with joint conditions, such as arthritis.
 V. Attempt Defibrillation with the AED, Defibrillator
A defibrillator is a device that gives a high energy electric shock to the heart of someone who is in cardiac

BLS for Adults arrest. This high energy shock is called defibrillation, and it's an essential part in trying to save the life of
someone who’s in cardiac arrest.
Monophasic: 360 joules
Biphasic: 120-200 joules

Pedia: Initial energy dose is 2 joules/kg

Subsequent defibrillations 4 joules/kg or higher with a maximum dose of 10 joules/kg
Infant pads are needed if the patient is under 10 kg or less than 1 year of age
If the patient is over 10 kg or 1 year of age, then adult pads are used
If small pads are not available, adult pads can be used in the anterior-posterior position

Continue CPR
 Do Not Move the Victim During Compressions
- unless the victim is in a dangerous environment (burning building) or if you cannot perform
CPR effectively in the victim’s present position or location.

BLS for Adults  Importance of a Firm Surface

- floor, backboard, cardiac board or spinal board
- a firm surface allows compression of the chest and heart to create blood flow

Chest Recoil
- allows blood flow to flow to the heart
- incomplete chest recoil reduces the filling of the heart between compressions and
reduces the blood flow created by chest compressions.
- Chest compression and chest recoil/relaxation times should be about EQUAL
 Opening the Airway
BLS for Adults  Head Tilt- Chin Lift
Caution:
Do not press deeply into the soft tissue under the chin because this might
block the airway
Do not close the victim’s mouth completely

 Jaw Thrust – head or neck (spinal) injury is suspected

 Opening the Airway
 Head Tilt- Chin Lift

Step Action

BLS for Adults 1 Place one hand on the victim’s forehead and push with your palm to tilt the head
back

2 Place the fingers of the other hand under the bony part of the lower jaw near the
chin.

3 Lift the jaw to bring the chin forward

 Opening the Airway
 Jaw Thrust – head or neck (spinal) injury is suspected

Step Action
BLS for Adults 1 Place one hand on each side of the victim’s head. You may rest your elbows on the
surface on which the victim is lying.
2 Place your fingers under the angles of the victim’s lower jaw and tilt with both
hands, displacing the jaw forward.
3 If the lips close, push the lower lip with your thumb to open the lips.
 Barrier Devices
Standard precautions include using barrier devices, such as a pocket mask,
when giving breaths.
Rescuers should replace face shields with a pocket mask at the first
opportunity
BLS for Adults
 Oxygen Content of Exhaled Air
- the air we breath in contains 21% oxygen

BLS for Adults - the air we breath out contains 17% oxygen
- because we use a relatively small amount of the oxygen we breathe , the
air that the rescuer breathes out provides the victim with much needed
oxygen
 Bag-Mask device/Bag-Valve-Mask device
- is used to provide positive-pressure ventilation to a victim who is not
breathing or not breathing normally

BLS for Adults - It consists of a bag attached to a face mask

- If the bag is self-inflating, a bag-mask device may be used with or without
an oxygen supply
- if not attached to O2 flow, it provides about 21% O at room air.
 Bag-Mask Ventilation Technique
Step Action

1 Position yourself directly above the victim’s head

2 Place the mask on the victim’s face, sing the bridge of the nose as a guide for
correct position.

BLS for Adults 3 Use the E-C clamp technique to hold the mask in place while you lift the jaw to
hold the airway open.
• Perform a head tilt
• Place a mask on the face with the narrow portion at the bridge of the nose
• Use the thumb and index finger of one hand to make a “C” on the side of the
mask, pressing the edges of the mask to the face.
• Use the remaining fingers to lift the angles of the jaw (33 fingers form an “E”),
open the airway, and press the face to the mask.
4 Squeeze the bag to give breaths (1 second each) while watching for chest rise.
Deliver each breath over 1 second, whether or not you use supplementary oxygen
 2-Rescuer CPR
Rescue/ Duties
Location
Rescuer 1 • Perform chest compressions
(Compression) - Compress at a rate of 100 to 120/min
At the victim’s side - Compress the chest at least 5 cm for adults
- Allow the chest to recoil completely after each compression
- Minimize interruptions in compressions (less than 10 seconds)
- Use a compression-to-ventilation ratio of 30:2
- Count compressions out loud.
• Switch compressors about every 5 cycles or every 2 minutes (or
more frequently if fatigued). Take less than 5 seconds to switch

BLS for Adults Rescuer 2

(Breaths)
• Maintain an open airway by using either
Head tilt – Chin lift or
At the victim’s Jaw thrust
head • Give breaths, watching for chest rise and avoiding excessive
ventilation
• Encourage the 1st rescuer to perform compression that are deep
enough and fast enough an to allow complete chest recoil between
compressions.
• When only 2 rescuers are available are available, switch
compressors about every 5 cycles or every 2 minutes, taking less
than 5 seconds to switch.
 Team Dynamics
Clear Roles during a Resuscitation Attempt
Team Leader – every resuscitation team must have a defined leader
• Assigns roles to team members
• Makes treatment decisions
• Provides feedback to the rest of the team as needed
BLS for Adults • Assumes responsibility for roles not assigned

Administer Medications
• An ACLS provider role
• Administers medications
 Team Dynamics
Clear Roles during a Resuscitation Attempt
Time/Recorder
• Records the time of interventions and medications (and announces when these
are next due)
• Records the frequency and duration of interruptions in compressions
BLS for Adults • Communicates these to the Team Leader (and the rest of the team)

Compressor
• Assess the patient
• Does 5 cycle of chest compressions
• Alternates with AED/monitor/Defibrillator every 5 cycles or 2 minutes or earlier
if signs of fatigue set in)
 Team Dynamics
Clear Roles during a Resuscitation Attempt
AED/(cardiac)monitor/Defibrillator
• Brings and operates the AED/monitor/Defibrillator
• Alternates with Compressor every 5 cycles or 2 minutes (or earlier if signs of
BLS for Adults fatigue set in), ideally during rhythm analysis
• If a monitor is present, places it in a position where it can be seen by the Team
Leader (and most of the team)
Airway
• Opens and maintains the airway
• Provides ventilation
 Team Dynamics
Knowing your Limitations
 Every member on the team should know his or her limitations and the team
leader should be aware of them
 Each member should ask for assistance and advice early, not when the situation
starts to get worse.
BLS for Adults Constructive Intervention
 Sometimes a team member or team leader may need to correct actions that are
incorrect or inappropriate.
 It is more important to be tactful, especially if you have to correct someone who
is about to correct mistake, whether it’s a drug, dose, or intervention
 Any person on the team should stop someone else from making a mistake,
regardless of that person’s role on the team
 Team Dynamics
What to Communicate
Knowledge Sharing – team leader should ask frequently for observations and
feedback, this includes good ideas for management and observations about
possible oversights
BLS for Adults Summarizing and Reevaluating – summarizing out loud is helpful during a
resuscitation attempt for the following reasons:
• Provides an ongoing record of treatment
• Reevaluate the victim’s status, interventions performed, and the team’s
progress
• Helps team members respond to the victim’s changing condition
 Team Dynamics
How to Communicate
Closed-Loop Communication:
Team Leader
• Call each member by name and make eye contact when giving an instruction
BLS for Adults  Don’t assign additional tasks until you are sure that the team member
understands the instruction
Team Members
 Confirm that you understand each task to which you are assigned by verbally
acknowledging the task
 Tell the team leader when you have finished a task
 Team Dynamics
How to Communicate
Clear Messages
 Using concise, clear language helps misunderstandings
 Speaking in a tone of voice that is loud enough to hear, but is also calm and
confident, helps keep all team leaders focused
BLS for Adults Mutual Respect
 All team members should display mutual respect and a professional attitude to
other team members, regardless of their skill level or training
 Emotions can run high during a resuscitation attempt.
 It’s important for the team leader to speak in a friendly, controlled voice and
avoid shouting or aggression
 Team Dynamics
Debriefing
 an important part of every resuscitation attempt, both during and after the
attempt.
BLS for Adults  An opportunity to identify why certain actions were taken
 Debriefing has been shown to:
• Help individual members perform better
• Aid in identification of system strengths and deficiencies
 Criteria When To Stop CPR
1. Notice Signs of Life
2. Life in Danger
3. A trained responder or emergency help takes over
4. You are too exhausted to continue
5. Obvious Death:
Cold to touch

BLS for Adults Rigor Mortis – “Stiffening”, caused by chemical changes in the muscles post
mortem; 3rd stage of death, 4 hours post-mortem
Livor Mortis (Lividity) - “Livor” refers to the bluish color you’ll find on
someone who has been deceased for several hours.
 It is caused by blood settling and eventually permeating the skin. It resembles
bruising but will cover large portions of the body.
- Lividity always occurs at a person’s center of gravity.
Injuries Not Compatible With Life – decapitation, amputation, etc.
- there is no blood to circulate with compressions and no red
blood cells to carry oxygen from rescue breaths.
 Signs of Poor Perfusion
• Temperature: Cool extremities
BLS for Adults • Altered mental state: Continued decline in consciousness/responsiveness
• Pulses: Weak pulses
• Skin: Paleness, mottling (patchy appearance), and later cyanosis (turning blue)
 Reference:
BLS for Adults American Heart Association
 ACLS Survey:
Assess Action as Appropriate

Airway • Maintain airway patency in unconscious

⁻ Is the airway patent? patients by use of the head tilt-chin lift, or
⁻ Is an advanced airway indicated oropharyngeal airway (OPA), or nasopharyngeal
ACLS - Is proper placement of airway device
confirmed?
airway (NPA)
• Use advanced airway management system if

Advance ⁻ Is tube secured and placement reconfirmed

frequently?
needed (e.g. laryngeal mask airway [LMA],
laryngeal tube, esophageal-tracheal tube,
endotracheal tube [ET])
Cardiac Life If using advanced airway devices:
• Confirm proper integration of CPR and
Support ventilation
• Confirm proper placement of advanced airway
devices by
- Physical examination
- Quantitative waveform capnography
• Secure the device to prevent dislodgment
• Monitor airway placement with continuous
quantitative waveform capnography
 ACLS Survey:
Assess Action as Appropriate

Breathing • Give supplementary oxygen when indicated

- Are ventilation and oxygenation adequate? - For cardiac arrest patients, administer 100%
- Are quantitative waveform capnography oxygen
ACLS and oxyhemoglobin saturation monitored? - For others, titrate oxygen administration to
achieve oxygen saturation values of >=94% by

Advance •
pulse oximetry
Monitor the adequacy of ventilation and
oxygenation by
Cardiac Life -
-
Clinical criteria (chest rise and cyanosis)
Quantitative waveform capnography
Support -
•
Oxygen saturation
Avoid excessive ventilation
 ACLS Survey:
Assess Action as Appropriate

Circulation • Monitor CPR quality

- Are chest compressions effective? - Quantitative waveform capnography (if PETCO2
- What is the cardiac rhythm? is <10 mmHg, attempt to improve CPR quality)
ACLS - Is defibrillation or cardioversion indicated?
- Has IV/IO access been established?
- Intra-arterial pressure (if relaxation phase
[diastolic] pressure is <20 mmHg, attempt to

Advance - Is ROSC present?

- Is the patient with a pulse unstable?
- Are medications needed for rhythm or
•
improve CPR quality
Attach monitor/defibrillator for arrhythmias or
cardiac arrest rhythms (eg. VF, pulseless VT,
Cardiac Life blood pressure?
- Does the patient need volume (fluid) for •
asystole, PEA)
Provide defibrillation/cardioversion
Support resuscitation? •
•
Obtain IV/IO access
Give IV/IO fluids if needed
 ACLS Survey:

Assess Action as Appropriate

Differential Diagnosis • Search for, find and treat reversible causes:
- Why did this patient develop symptoms or 5 Hs & 5 Ts:
arrest? - Hypovolemia, Hypoxia, Hydrogen ion (acidosis,
- Is there a reversible cause that can be Hypo/Hyperkalemia, Hypothermia

ACLS
treated? - Tension Pneumothorax, Tamponade (Cardiac),
Toxins, Thrombosis (Pulmonary), Thrombosis
(Coronary)
Advance
Cardiac Life
Support PETCO2 is the partial pressure of CO2 in exhaled air at the end of the exhalation phase.
OPA/NPA
Advanced
Airway
Adjuncts
PETCO2
 Therapeutic Hypothermia
 Cooling comatose (ie. Lack of meaningful response to verbal
commands) adult patients with ROSC after out-of-hospital VF
Post-Cardiac Arrest cardiac arrest to 32-34C for 12-24 hours
Care  Induced hypothermia for comatose adult patients with ROSC after
in-hospital cardiac arrest of any initial rhythm or after-hospital
cardiac arrest with an initial rhythm of PEA or asystole
 Hemodynamic and Ventilation Optimization
 Providers should titrate inspired oxygen during the post-cardiac arrest
phase to the lowest level required to achieve an arterial oxygen
saturation of >=94%. This helps to avoid any potential complications
associated toxicity
 Avoid excessive ventilation of the patient because of potential adverse
hemodynamic effects when intrathoracic pressures are increased and
Post-Cardiac Arrest because of potential decreases in cerebral flow when PaCO2 decreases
Care  Healthcare providers may start ventilation rates at 10-12 breaths per
minute and titrate to achieve a PETCO2 of 35 to 40 mmHg or a PaCO2
of 40-45 mmHg
 Healthcare providers should titrate fluid administration and vasoactive
or inotropic agents as needed to optimize blood pressure, cardiac
output, and systemic perfusion. A mean arterial pressure >= 65 mmHg is
a reasonable goal.
 Immediate Coronary Reperfusion with PCI
 Following ROSC, rescuers should transport the patient to a facility
capable of reliably providing coronary reperfusion (eg. PCI) and other
Post-Cardiac Arrest goal-directed post-arrest care therapies.

Care  The decision to perform PCI can be made irrespective of he presence of

coma or the decision to induced hypothermia, because concurrent PCI
and hypothermia are reported to be feasible and safe and have good
outcomes
 Glycemic Control
 Consider strategies target moderate glycemic control (144 to 180 mg/dl [8-
Post-Cardiac Arrest 10 mmol/L]) in adult patients with ROSC after cardiac arrest.

Care  Healthcare providers should not attempt to alter glucose concentration

within a lower range (80-110 mg/dl [4.4 to 6.1 mmol/L]) due to the increased
risk of hypoglycemia.
 Neurologic Care and Prognostication
 The goal of post-cardiac arrest management is to return patients to their
Post-Cardiac Arrest pre-arrest functional level.
Care  Early prognostication of neurologic outcome is an essential component of
post-cardiac arrest care.
 Primary goals of therapy for patients with ACS:
 Reduce the amount of myocardial necrosis, thus preserving left ventricular
(LV) function, preventing heart failure and limiting cardiovascular
complications
Acute Coronary  Prevent major adverse cardiac events (MACE): death, nonfatal MI and the
Syndromes need for urgent revascularization
 Treat acute, life-threatening complications of ACS, such as VF, pulseless VT,
unstable tachycardias, symptomatic bradycardias, pulmonary edema,
cardiogenic shock, and mechanical complications of AMI
 Hospital-Based Components
 Emergency department (ED) protocols
 Activation of the cardiac catheterization laboratory
Acute Coronary
 Admission to the coronary intensive care unit (ICU)
Syndromes
 Quality assurance, real-time feedback, and healthcare provider education
  Emergency Physician
 Empowered to select the most appropriate reperfusion strategy
Acute Coronary
 Empowered to activate the cardiac catheterization team as indicated
Syndromes
  Hospital Leadership
Acute Coronary - Must be involved in the process and committed to support rapid access to
Syndromes STEMI reperfusion therapy
  Creation of stroke centers
 Recombinant plasminogen activator (rTPA)
 Patient education must clear and succinct
 Education efforts need to couple the knowledge of the signs and symptoms
Acute Stroke of stoke with action – activate the EMS
 EMS response personnel trained in stroke recognition
 Stroke-prepared hospitals-primary stroke centers
 Access to stroke expertise via telemedicine from the nearest stroke center