AED	Automated external defibrillator
AHA	American Heart Association
BLS	Basic Life Support
CPR	Cardiopulmonary resuscitation
ECC	Emergency Cardiovascular Care
EMS	Emergency Medical Services
MET	Medical Emergency Team
RRT	Rapid Response Team
SCA	Sudden cardiac arrest
VF; V-fib	Ventricular fibrillation

Emergencies can occur anywhere. Sometimes you can save a life if you know what to do. First aid and Basic Life Support (BLS) courses prepare you to give emergency care.

The BLS procedures in this chapter are given as basic information. They do not replace certification training. You need a BLS course for health care providers.

BLS guidelines are updated as new information becomes available. You are responsible for following current guidelines. Emergency Cardiovascular Care (ECC) updates can be found on-line at ECCguidelines.heart.org.

Emergency Care

First aid is the emergency care given to an ill or injured person before medical help arrives. The goals of first aid are to:

• Prevent death.

• Prevent injuries from becoming worse.

In an emergency, the Emergency Medical Services (EMS) system is activated. Emergency personnel (paramedics, emergency medical technicians) rush to the scene. They treat, stabilize, and transport persons with life-threatening problems. They have guidelines for care and communicate with doctors in hospital emergency rooms. The doctors can direct their care. Their ambulances have emergency drugs, equipment, and supplies. To activate the EMS system, do 1 of the following.

• Dial 911.

• Call the local fire or police department.

• Call the phone operator.

Each emergency is different. The rules in Box 54-1 apply to any emergency. Hospitals and other agencies have procedures for emergencies. Rapid Response Teams (RRTs) or Medical Emergency Teams (METs) are called when a person shows warning signs of a life-threatening condition. An RRT (MET) may include a doctor, a nurse, and a respiratory therapist. The RRT’s (MET’s) goal is to prevent death.

Box 54-1

Emergency Care Rules

• Wait for help to arrive if the scene is not safe enough for you to approach.

• Know your limits. Do not do more than you are able. Do not perform an unfamiliar procedure. Do what you can under the circumstances.

• Stay calm. This helps the person feel more secure.

• Know where to find emergency supplies.

• Follow Standard Precautions and the Bloodborne Pathogen Standard to the extent possible.

• Check for life-threatening problems. Check for breathing, a pulse, and bleeding.

• Keep the person lying down or as you found him or her. Moving the person could make an injury worse.

• Move the person only if the setting is unsafe. Examples include:

• A burning car or building

• A building that might collapse

• Stormy conditions with lightning

• In water

• Near electrical wires

• Perform necessary emergency measures.

• Call for help. Or have someone activate the EMS system. Do not hang up until the operator has hung up. Give the following information.

• Your location—street address and city, cross streets or roads, and landmarks

• Phone number you are calling from

• What seems to have happened (for example: heart attack, crash, fire)—police, fire equipment, and ambulances may be needed

• How many people need help

• Conditions of victims, obvious injuries, and life-threatening situations

• What aid is being given

• Do not remove clothes unless you have to. If you must remove clothing, tear or cut garments along the seams. (For CPR, remove clothing or move it out of the way. See p. 832.)

• Keep the person warm. Cover the person with a blanket, coats, or sweaters.

• Reassure the person. Explain what is happening and that help was called.

• Do not give the person fluids.

• Keep on-lookers away. They invade privacy and tend to stare, give advice, and comment about the person’s condition. The person may think the situation is worse than it is.

See Focus on Communication: Emergency Care.

See Focus on Long-Term Care and Home Care: Emergency Care.

See Promoting Safety and Comfort: Emergency Care.

Focus on Communication

Emergency Care

Some illnesses and injuries are life-threatening. To find out what happened and the person’s condition, you can say:

• “Are you okay?”

• “Tell me what’s wrong.”

• “Where does it hurt?”

• “If you can, please point to where it hurts.”

• “Can you move your arms and legs?”

Focus on Long-Term Care and Home Care

Emergency Care

Long-Term Care

In nursing centers, a nurse decides when to activate the EMS system. The nurse tells you how to help. If a person has stopped breathing or is in sudden cardiac arrest, the nurse may start cardiopulmonary resuscitation (CPR). Some centers allow nursing assistants to start CPR. Others do not. Know your center’s policy about CPR.

Death is expected in persons with terminal illnesses. Usually these persons are not resuscitated (Chapter 55). This information is in the care plan.

Promoting Safety and Comfort

Emergency Care

Safety

During emergencies, contact with blood, body fluids, secretions, and excretions is likely. Follow Standard Precautions and the Bloodborne Pathogen Standard to the extent possible.

When an emergency occurs in an agency, call for the nurse at once. You may need to activate the EMS system or the RRT (MET). Or you take the person’s vital signs (Chapter 29). Assist as instructed by the nurse.

Comfort

Mental comfort is important during emergencies. Help the person feel safe and secure. Give reassurance. Explain the care you provide. Use a calm approach.

BLS for Adults

When the heart and breathing stop, the person is clinically dead. Blood is not circulated through the body. Heart, brain, and other organ damage occurs within minutes. The American Heart Association’s (AHA’s) BLS procedures support circulation and breathing.

Sudden Cardiac Arrest

Sudden cardiac arrest (SCA) or cardiac arrest is when the heart stops suddenly and without warning. Within moments, breathing stops as well. Permanent brain and other organ damage occurs unless circulation and breathing are restored. There are 3 major signs of SCA.

• No response.

• No breathing or no normal breathing. The person may have agonal gasps or agonal respirations early during SCA. (Agonal means to struggle. Agonal is used in relation to death and dying.) Agonal gasps do not bring enough oxygen into the lungs. Agonal gasps are not normal breathing.

• No pulse.

The person’s skin is cool, pale, and gray. The person is not coughing or moving.

SCA is a sudden, unexpected, and dramatic event. It can occur anywhere and at any time—while driving, shoveling snow, playing golf or tennis, watching TV, eating, or sleeping. Common causes include heart disease, heart attack, enlarged heart, heart valve problems, dysrhythmias (arrhythmias), and congenital heart defects (Chapter 45). Electrical shock, chest trauma, and illegal drug use are other causes. These causes lead to an abnormal heart rhythm called ventricular fibrillation (p. 835). The heart cannot pump blood. A normal rhythm must be restored. Otherwise the person will die.

Chains of Survival.

The AHA’s BLS courses teach Chains of Survival. The Chains of Survival identify the different pathways of care for in-hospital and out-of-hospital cardiac arrests (Box 54-2). Care is provided as soon as possible. Any delay reduces the person’s chance of surviving.

Box 54-2

Chains of Survival

In-Hospital Chain of Survival

1. Surveillance and prevention.

2. Recognizing cardiac arrest and activating the EMS system.

3. Immediate high-quality CPR.

4. Rapid defibrillation. See p. 835.

5. Advanced life support and post-arrest care. This is care given to improve survival following cardiac arrest.

Out-of-Hospital Chain of Survival

1. Recognizing cardiac arrest and activating the EMS system.

2. Immediate high-quality CPR.

3. Rapid defibrillation.

4. Basic and advanced EMS. Care is given by EMS staff, doctors, nurses, and respiratory therapists. They give drugs and perform life-saving measures.

5. Advanced life support and post-arrest care.

See Focus on Communication: Chains of Survival.

Focus on Communication

Chains of Survival

Getting help is a critical step. If alone, activate the EMS system using your wireless phone while continuing to give care. If alone with no wireless phone, leave the adult to activate the EMS system and get an AED yourself before giving care. (AED stands for automated external defibrillator. See p. 835.) Guidelines for children and infants differ from adult guidelines. See p. 839.

If others are around, tell a certain person to activate the EMS system. You may not know the person’s name. Point to the person. Make eye contact. You can say: “Call 911 and get an AED.” Begin care. Follow up soon. Make sure the person was able to call for help.

Respiratory Arrest

Respiratory arrest is when breathing stops but heart action continues for several minutes. If breathing is not restored, cardiac arrest occurs. Respiratory arrest can occur from:

• Problems affecting nerves, muscles, or areas of the brain that control breathing—amyotrophic lateral sclerosis (ALS), spinal cord injuries, stroke (Chapter 44); drug or alcohol over-dose; drug side-effects

• Damage to the lungs—injury to the chest

• Lung disorders and problems—pneumonia, chronic obstructive pulmonary disease (Chapter 45), pulmonary embolism (Chapter 35)

• Blocked airflow—choking (Chapter 13 and p. 844), drowning, suffocation

• Inhaling harmful substances—smoke, chemicals, fumes

Rescue Breathing.

Rescue breaths are given when there is a pulse but no breathing or only agonal gasping. To give rescue breaths:

• Open the airway (p. 833).

• Give 1 breath every 5 to 6 seconds for adults.

• Give 1 breath every 3 to 5 seconds for infants and children.

• Give each breath over 1 second. The chest should rise when breaths are given.

• Check the pulse every 2 minutes. If there is no pulse, begin CPR. If the pulse is 60 or less in an infant or child, begin CPR (p. 839).

Adult CPR

When the heart and breathing stop, blood and oxygen are not supplied to the body. Brain and other organ damage occurs within minutes.

CPR must be started at once when a person has SCA. CPR supports circulation and breathing. It provides blood and oxygen to the heart, brain, and other organs until advanced emergency care is given. CPR involves:

CPR procedures require speed, skill, and efficiency.

See Promoting Safety and Comfort: Adult CPR, p. 832.

Promoting Safety and Comfort

Adult CPR

Safety

The discussion and procedures that follow assume that the person does not have injuries from trauma (Chapter 36). If injuries are present, special measures are needed to position the person and open the airway. Such measures are learned during a BLS certification course.

Chest Compressions.

The heart, brain, and other organs must receive blood. Otherwise, permanent damage results. In cardiac arrest, the heart has stopped beating. Blood must be pumped through the body another way. Chest compressions force blood through the circulatory system.

Before starting chest compressions, check for a pulse. Use the carotid artery on the side near you. To find the carotid pulse, place 2 or 3 fingertips on the trachea (windpipe). Then slide your fingers down off the trachea to the groove of the neck (Fig. 54-1). Check for a pulse for no more than 10 seconds. While checking for a pulse, look for signs of circulation. See if the person has started breathing or is coughing or moving.

FIGURE 54-1 Locating the carotid pulse. A, Two fingers are placed on the trachea. B, The fingertips are moved down into the groove of the neck to the carotid artery.

The heart lies between the sternum (breastbone) and the spinal column. When pressure is applied to the sternum, the sternum is depressed (moved down). This compresses the heart between the sternum and spinal column (Fig. 54-2). For effective chest compressions, the person must be supine on a hard, flat surface—floor or back-board. You are positioned at the person’s side.

FIGURE 54-2 The heart lies between the sternum and the spinal column. The heart is compressed when pressure is applied to the sternum.

Hand position is important for effective chest compressions (Fig. 54-3). You use the heels of your hands—1 on top of the other—for chest compressions. For proper placement:

• Expose the person’s chest. Remove clothing or move it out of the way. You need to see the person’s bare skin for proper hand position.

• Place the heel of 1 hand (usually your dominant hand) in the center of the bare chest. The heel of this hand is placed between the nipples on the lower half of the sternum.

• Place the heel of your other hand on top of the heel of the first hand.

FIGURE 54-3 Proper hand position for CPR. A, The heel of the dominant hand is placed in the center of the chest. It is between the nipples and on the lower half of the sternum. B, The heel of the non-dominant hand is placed on top of the dominant hand.

To give chest compressions, your arms are straight. Your shoulders are directly over your hands. And your fingers are interlocked (Fig. 54-4). Exert firm downward pressure to depress the average adult sternum at least 2 inches. According to AHA guidelines, avoid pressing down more than 2.4 inches. Then release pressure without removing your hands from the chest. Avoid leaning on the chest between compressions. Releasing pressure allows the chest to recoil—to return to its normal position. Recoil lets the heart fill with blood.

FIGURE 54-4 Giving chest compressions. The arms are straight. The shoulders are over the hands. The fingers are interlocked.

The AHA recommends that you:

• Give compressions at a rate of 100 to 120 per minute.

• Interrupt chest compressions only when necessary. Interruptions should be less than 10 seconds. When there are no chest compressions, blood does not flow to the heart, brain, and other organs.

Airway.

The respiratory passages (airway) must be open to restore breathing. The airway is often obstructed (blocked) during SCA. The person’s tongue falls toward the back of the throat and blocks the airway. The head tilt–chin lift method opens the airway (Fig. 54-5).

• Place the palm of 1 hand on the forehead.

• Tilt the head back by pushing down on the forehead with your palm.

• Place the fingers of your other hand under the lower jaw. Use your index and middle fingers. Do not use your thumb.

• Lift the jaw. This brings the chin forward.

• Do not close the person’s mouth. The mouth should be slightly open.

FIGURE 54-5 The head tilt–chin lift method opens the airway. One hand is on the person’s forehead. Pressure is applied to tilt the head back. The chin is lifted with the fingers of the other hand.

Breathing.

Air is not inhaled when breathing stops. The person must get oxygen. If not, permanent heart, brain, and other organ damage occurs. The person is given breaths. That is, a rescuer inflates the person’s lungs.

Each breath should take 1 second. You should see the chest rise with each breath. Two breaths are given after every 30 chest compressions.

See Focus on Children and Older Persons: Breathing.

Focus on Children and Older Persons

Breathing

Children

When 2 rescuers perform CPR on an infant or child, 2 breaths are given after every 15 compressions (p. 839).

Mouth-to-Mouth Breathing.

Mouth-to-mouth breathing (Fig. 54-6) is one way to give breaths. You place your mouth over the person’s mouth. Contact with the person’s blood, body fluids, secretions, or excretions is likely. To give mouth-to-mouth breathing:

Barrier Device Breathing.

A barrier device is used for giving breaths whenever possible. The device prevents contact with the person’s mouth and blood, body fluids, secretions, or excretions. A face shield may be used (Fig. 54-7). A face shield is replaced with a face mask as soon as possible (Fig. 54-8, A). The mask is placed over the person’s mouth and nose (Fig. 54-8, B). When using a barrier device, seal the device against the person’s face. The seal must be tight. Then open the airway with the head tilt–chin lift method.

FIGURE 54-7 A, Face shield. B, The face shield is in place.

FIGURE 54-8 A, Mask for giving breaths. B, The mask is in place.

A bag valve mask (Fig. 54-9) is another device used to give rescue breaths. The device consists of a hand-held bag attached to a mask. The mask is held securely to the person’s face. The bag is squeezed to give breaths. The bag can be connected to an oxygen source.

Mouth-to-Nose Breathing.

Mouth-to-nose breathing is used when:

• You cannot breathe through the person’s mouth.

• You cannot open the mouth.

• Your mouth is too small to make a tight seal for mouth-to-mouth breathing.

• The mouth or jaw is severely injured.

• The person is bleeding from the mouth.

The mouth is closed for mouth-to-nose breathing. The head tilt–chin lift method opens the airway. Pressure is placed on the chin to close the mouth. To give a breath, place your mouth over the person’s nose and blow air into the nose (Fig. 54-10). After giving a breath, remove your mouth from the person’s nose.

Mouth-to-Stoma Breathing.

Some people breathe through stomas (openings) in their necks (Fig. 54-11). To give mouth-to-stoma breathing:

1. Keep the person’s mouth closed.

2. Do not tilt the person’s head back.

3. Seal your mouth around the stoma.

4. Blow air into the stoma (Fig. 54-12).

If the person’s chest does not rise, you may need to pinch the nostrils shut.

FIGURE 54-11 A stoma in the neck. The person breathes in and out of the stoma.

Before giving mouth-to-mouth or mouth-to-nose breathing, always check to see if the person has a stoma. Other rescue breathing methods are not effective if the person has a stoma.

Defibrillation.

Ventricular fibrillation (VF, V-fib) is an abnormal heart rhythm (Fig. 54-13, p. 836). It causes sudden cardiac arrest. Rather than beating in a regular rhythm, the heart shakes and quivers like a bowl of Jell-O. The heart does not pump blood. The heart, brain, and other organs do not receive blood and oxygen.

FIGURE 54-13 A, Normal rhythm. B, Ventricular fibrillation. (From Ignatavicius DD, Workman ML: Medical-surgical nursing: patient-centered collaborative care, ed 7, St Louis, 2013, Saunders.)

A defibrillator is used to deliver a shock to the heart. The shock stops the VF (V-fib). This allows the return of a regular heart rhythm. Defibrillation as soon as possible after the onset of VF (V-fib) increases the person’s chance of survival.

For adults, the AHA recommends that rescuers:

• Use an AED as soon as possible.

• Minimize interruptions in chest compressions before and after a shock is given. CPR is given while the AED pads are applied and until the AED is ready to check the rhythm.

• Give 1 shock. Then resume CPR at once. Begin with chest compressions.

• Check for a heart rhythm again after about 2 minutes of CPR (when prompted by the AED).

AEDs are found in health care agencies (Fig. 54-14, p. 836). They are on airplanes and in airports, health clubs, malls, and other public places. Some people have them in their homes.

FIGURE 54-14 An automated external defibrillator (AED).

You will learn more about using an AED in the AHA’s BLS for Healthcare Providers course.

See Focus on Children and Older Persons: Defibrillation, p. 836.

Focus on Children and Older Persons

Defibrillation

Children

Some AEDs are designed for adults and children. A key or switch is used to change the dosage. Or child pads are used. Always follow the manufacturer’s instructions.

The shock dosage for children 8 years and older is the same as the adult dosage. Lower shock dosages are used for children younger than 8 years. For infants, a manual defibrillator is best. Trained staff and EMS use the defibrillator. If one is not available, an AED with child dosages may be used. If neither is available, adult dosages may be used. If adult pads are used, the pads must not touch or over-lap.

Performing Adult CPR.

CPR is done only for cardiac arrest. You must determine if cardiac arrest or fainting (p. 845) has occurred. CPR is done if the person does not respond, is not breathing or only gasping (has no normal breathing ), and has no pulse.

CPR is done alone or with another person. When done alone, chest compressions and breaths are given by 1 rescuer. With 2 rescuers, 1 person gives chest compressions and the other gives breaths (Fig. 54-15). Rescuers switch tasks about every 2 minutes to avoid fatigue and inadequate compressions. The second rescuer uses the AED if one is available.

See Focus on Communication: Performing Adult CPR.

See Promoting Safety and Comfort: Performing Adult CPR.

See procedure: Adult CPR—1 Rescuer.

See procedure: Adult CPR With AED—2 Rescuers.

Focus on Communication

Performing Adult CPR

Good communication is needed when 2 rescuers perform CPR. The rescuer giving compressions must count out loud so the other rescuer is ready to give breaths. Clear communication prevents delays and minimizes interruptions in chest compressions.

Promoting Safety and Comfort

Performing Adult CPR

Safety

Never practice CPR on another person. Serious damage can be done. Mannequins are used to learn and practice CPR.

Make sure you have a safe setting for CPR. Move the person only if the setting is unsafe (see Box 54-1). Do not approach the person if the scene is unsafe for you.

The person must be on a hard, flat surface for CPR. Logroll the person so there is no twisting of the spine. Place the arms alongside the body. If the person is in bed, you may need to place a board under the person. Or move the person to the floor.

Basic Life Support guidelines are updated as new information becomes available. You are responsible for following current guidelines. Updates can be found on-line at ECCguidelines.heart.org.

Adult CPR—1 Rescuer