BLS Study Guide

Chapter 1: Introduction to Basic Life Support

Basic Life Support refers to procedures that healthcare providers can learn to prolong survival in life-threatening emergencies such as cardiac arrest, respiratory arrest, or an obstructed airway. It requires knowledge and skills in cardiopulmonary resuscitation, automated external defibrillators, and relieving airway obstructions in patients of every age.

The guidelines in Basic Life Support are frequently updated based on the latest evidence available, and every individual who undergoes BLS certification may need to refresh their knowledge every two years.

Healthcare professionals usually know basic life support guidelines. However, they must still undergo certifications to update their knowledge and skills regarding the latest evidence-based protocols.

Why Do We Need Basic Life Support?

BLS is needed to improve patient outcomes and prolong life until the victim gets advanced life support. Access to immediate basic life support has increased survival rates and viable brain function.

Chapter 2: Basic Anatomy and Physiology

In Basic Life Support, knowing and understanding how the heart, lungs, brain, and cells perform in our body is essential. Here is a brief function of these systems:

Heart: The heart pumps blood that has been deoxygenated by supplying the body's tissues into the lungs. When that blood has been oxygenated in the lungs, it exits the lungs to the left side of the heart, pumped out into the tissues once again to provide oxygen.

Lungs: The lungs use oxygen to supply the body's vital organs and tissues. They release carbon dioxide into the atmosphere when we exhale.

Brain: The brain needs a steady supply of oxygen. It uses 20% of the body's oxygen. Without it, the brain cells begin to die in 4 to 6 minutes.

Cells: All cells in the body require oxygen to perform their normal functions. Cells will die in just a few minutes when deprived of oxygen.

Chapter 3: Understanding CPR

According to the Center for Disease Control, Cardiac Arrest is the leading cause of death in the United States. Risk factors include smoking, high blood pressure, high cholesterol, lack of exercise, stress, and obesity. There are also unavoidable factors such as age, sex, hereditary, and diabetes.

Death is most likely during out-of-hospital cardiac emergencies after 10 minutes of losing oxygen to the brain. Brain damage is expected within 6 to 10 minutes. Therefore, the rescuer should perform CPR in the 1st 4 minutes to avoid brain damage. It's important to note that the American Heart Association guidelines recommend untrained bystanders to at least perform chest compressions on the patient since studies show chest compressions can be as effective as the combination of CPR.

Chest Compressions: This procedure replicates the heart's pumping action from the outside. Once high-quality chest compressions are administered, the blood moves to the body's vital parts. Current protocols emphasize hands-only CPR if only one rescuer is present. This technique involves only chest compressions without artificial breathing.

Rescue Breathing: During this procedure, the rescuer manually breathes air into the victim's lungs, which simulates the act of inhalation. The air helps oxygenate the blood flowing through the lungs. The air mostly consists of carbon dioxide. But, it also contains all the oxygen that the rescuer's body did not use, constituting almost 17% of the exhaled air. This is enough to sustain the life of the victim until the emergency response team takes over.

Before giving rescue breath, open the victim's airway using a head tilt, chin lift or jaw thrust maneuver if there is suspected spine and neck injury. Avoid excessive ventilation, and chest rise should appear natural.

• Adults: 1 breath every 5 - 6 seconds (10-12 breaths per minute)
• Children and infants: 1 breath every 3 - 5 seconds (12-20 breaths per minute)

When to Stop CPR

• The patient regains a pulse
• The area becomes unsafe
• The cardiac arrest last longer than 30 minutes
• The rescuer is too exhausted or ordered to stop

Chapter 4: What is the Chain of Survival?

Keep the Emergency Cardiovascular Care's Chain of Survival when preparing to perform CPR. These are the five universal steps that you must perform in an emergency:

• Immediate recognition of cardiac arrest, call 911.
• CPR with emphasis on chest compressions. Continue CPR until medics arrive.
• Provide rapid defibrillation with an AED (necessary to restore a normal heartbeat) within minutes of the onset of symptoms.
• Trained physicians administer advanced life support.
• Post-cardiac arrest care is administered in a hospital setting.

Pediatric Chain of Survival

• Prevention of respiratory/cardiac arrest
• Early high-quality CPR
• Activation of the Emergency Response System
• Early advanced life support
• Comprehensive post-cardiac arrest care

Chapter 5: What is Hands-Only CPR?

Untrained bystanders should provide hands-only CPR or compression-only CPR for adult cardiac arrest victims, with or without dispatcher guidance. The rescuer should do continuous chest compressions until an AED or emergency response team arrives. Hands-Only CPR can be enough to sustain an adult in certain situations until help arrives.

Step 1: Call 911 If you have witnessed an adult collapse before you, you should first call 911. If bystanders are with you or within shouting distance, you should begin Hands-Only CPR and tell the other person to call 911 immediately.

Step 2: Place the victim on their back on a hard, flat surface. Kneel next to the victim. Then place the heel of one palm on the center of the chest and in line with the victim's nipples. Put your other hand on top of your first hand, interlocking your fingers. Keep your arms and back straight.

Step 3: Chest Compressions

• Chest compressions are performed at a depth of 2-2.4 inches for adults and 2 inches for children.
• Deliver compressions quickly and forcefully to help circulate the remaining oxygenated blood to the brain. The compression rate is 100-120 chest compression per minute. Keep in mind that 120/minute is pretty fast.
• Allow complete chest recoil for each compression.

Step 4: Continue chest compressions only until professional help arrives.
According to the American Heart Association guidelines, Hands-Only CPR is appropriate only for adults that you have observed become unconscious or stop breathing. It is not recommended for infants and children and is not appropriate for an adult you have found unconscious. Still, Hands-Only CPR can be a useful option for those not certified in CPR or those who haven't recertified in a long time.

Chapter 6: The Team Approach

There are emergency situations where more than one rescuer trained are present and willing to help. This is where you can use a team approach in Basic Life Support.

• The first rescuer will act as the team leader.
• One rescuer can provide chest compressions
• One can prepare to give rescue breaths with a bag-valve-mask
• One can prepare the AED.

Most rescuers find that they become very fatigued after providing compressions for 2 or 3 minutes. When this happens, there is a tendency to compress less firmly and more slowly, resulting in ineffective chest compressions. So it's recommended that rescuers trade off doing compressions every 2 minutes to prevent fatigue and optimize the quality of compressions. By working together, you can give the most efficient care to the patient.

Chapter 7: One Rescuer Adult CPR

If you are alone and come across an unresponsive victim, follow the steps below:

Step 1: Check for consciousness. To check for consciousness, tap on the victim's shoulder firmly and ask, "Are you OK?" loudly.

Step 2: Call 911 or ask someone else to call before performing CPR. Even if you perform CPR on the spot, getting paramedics to the scene as quickly as possible is crucial. If possible, ask a bystander to look for an AED.

Step 3: Check for breathing and open the airway. Check the breathing for about 10 seconds. If the breathing is normal, put the victim in the recovery position and wait for the responders to arrive. If you do not hear breathing or the victim has abnormal breathing, begin CPR immediately.

Step 4: Begin CPR Place the victim on their back on a firm, flat surface. Alternate between 30 chest compressions and two rescue breaths, with 2 inches of compression depth at a rate of 100-120 compressions per minute. Blow until the chest rises.

Step 5: Use AED if available If an AED is available, a bystander in a public place or a family member can use it to deliver an electric shock to the heart to restore regular rhythm.

Chapter 8: 2-Rescuer CPR for Adult

If you encounter an unconscious victim and another rescuer is available to help, ask them to call 911 and find an AED while assessing whether the victim needs high-quality CPR. If the victim requires CPR, start with compressions.

How to perform CPR when there are two rescuers present?

Step 1: Check for consciousness.Tap the victim's shoulder and ask if they are okay. If the victim is not breathing, gasping (agonal breathing, or has abnormal breathing, stay with the victim.

Step 2: Call 911. Rescuer 2 will call 911 and leaves to retrieve an AED.

Step 3: Check for breathing and pulse. Rescuer 1 checks for a pulse. If there's no pulse, the rescuer will begin CPR, starting with chest compressions.

Step 4: Begin CPR Rescuer 1 will give chest compressions and rescue breaths until Rescuer 2 returns with an AED.

Step 5: Use an AED

• When the 2nd rescuer arrives with an AED, place it on the side opposite Rescuer 1, who is performing CPR.
• Rescuer 2 will turn on the AED and attaches the pads to the victim's chest. Rescuer 1 will continue CPR until it is time to analyze the heart rhythm.
• Rescuer 2 clears the victim, ensuring neither rescuer touches the victim and waits for the AED to analyze.
• Rescuer 2 will push the SHOCK button if a shock is indicated.
• If no shock is needed, rescuer 2 will resume chest compressions.
• During analysis, Rescuer 2 and Rescuer 1 should switch positions to prevent rescuer fatigue and ensure that rescuers provide high-quality chest compressions at the proper rate and depth.

When the second rescuer returns without an AED:

• Continue performing chest compressions and count the compressions aloud.
• Rescuer 2 must keep the victim's airway open to give 2 rescue breaths after every 30 compressions.
• Rescuers should switch positions every two minutes to avoid fatigue.

Chapter 9: One-Rescuer Child CPR

If you are the only person available to help a child, do the following:

1. Check for responsiveness. Check the child's responsiveness by shaking their shoulders, calling their name, and asking if they are okay. Check for breathing. If there is no breathing or the child is just gasping, call 911
2. Activate EMS. If you see the child’s collapse, leave the victim to call 911 and retrieve an AED. If you did not witness the child collapse, give 2 minutes of CPR then call 911 and get an AED and return to the victim to resume CPR

Chest compressions:

• Compression to Ventilation Ratio: 30:2
• Hand Placement for Child CPR: You can use 1 or 2 hands on the lower half of the breastbone (sternum)

• Compression Rate: 100-120 compressions per minute.
• Chest recoil: Allow a full recoil after each chest compression
• Minimizing interruptions: Limit compression interruptions to less than 10 seconds.

Rescue Breathing:

• Open the airway using the head tilt-chin lift.
• Place the bag-mask device or barrier device on the child’s face using the bridge of the nose as a guide.
• Create a proper seal to avoid the air from escaping
• Rescue breath should last 1 second, enough to make the chest rise.
• Avoid excessive ventilation
• Chest rise should appear natural and gradual rather than sudden and forceful.

3. Use the AED as soon as possible.

Chapter 10: Two-Rescuer Child CPR

When two rescuers are available to respond, the procedure of two rescuer child CPR is the same adults:

• Compression to ventilation ratio: 15:2
• Hand Placement: One or two hands may be used to compress the chest to
• Compression Depth: 2 inches deep
• Compression Rate: 100-120 compressions per minute

Chapter 11: How to Administer CPR on Infants?

Infant CPR has many similarities with child and adult CPR, but special accommodations must be made in hand position and compression depth due to the infant's small size. When administering infant CPR, use the same cycles of compressions and rescue breaths.

• Checking for responsiveness: Do not shake the infant as it may cause brain damage. To check if the infant is responsive, tap the bottom of the feet while talking to the infant loudly.
• Activating EMS: When to call EMS depends on whether you witnessed the infant's arrest or not. If you did not witness the infant collapse and are alone, you should provide 2 minutes of CPR before calling EMS and finding an AED. If you witness the arrest, you should call EMS and get an AED before returning to the child to start CPR.
• Depth of Compression: 1 ½ inch deep or at least one-third of the depth of the infant's chest.
• Hand placement: Compressed using two fingers on the lower half of the sternum, avoiding the xiphoid process.
• Compression to ventilation: 15:2 if two rescuers are present.

Chapter 12: What is an Automated External Defibrillator (AED)?

An AED is a mechanical device designed to assess the electrical output of a victim's heart and provide an electrical shock if needed. It is utilized when a victim experiences sudden cardiac arrest.

An AED is a mechanical device designed to assess the electrical output of a victim's heart and provide an electrical shock if needed. It is utilized when a victim experiences sudden cardiac arrest.

• Heart Rhythm: The heart's rhythm is determined by electrical impulses spontaneously generated from a certain point in the upper heart, called the sino-atrial node.
• Arrhythmias: When the electrical impulses occur too fast, the heartbeat becomes irregular. Abnormal heart rhythms are referred to as Arrhythmias.
• Ventricular fibrillation: During Ventricular fibrillation is disordered electrical activity in the ventricles. As a result, the heartbeat is completely unsynchronized, and the heart begins to quiver instead of pumping blood.
• Pulseless Ventricular Tachycardia: A type of arrhythmias when the ventricles begin to contract at an extremely fast pace. This results in inefficient pumping of blood. You won't be able to feel a pulse due to the fast pace.

When ventricular fibrillation and pulseless ventricular tachycardia are present, the AED can "shock" the heart into regaining its normal rhythm.

How to use an AED?

• Assess the victim for SCA.
• Immediately call 911. If more than one rescuer is present, provide CPR while the AED is retrieved and prepared.
• Once powered on, the machine will instruct the rescuer to place the electrodes (pads) over the victim's heart. If the victim has a hairy chest, shave the area that will be covered by electrode pads.
• Choose adult pads for victims who are eight years of age or older. You may use adult pads for children below eight years old, if child pads are not available but you should ensure the pads do not touch or overlap.
• A manual defibrillator is preferred in infants.
• The AED will scan the victim's heart, checking if the shock is necessary. Ensure that no one is in contact with the victim while the AED assesses the victim.
• Rescuers should follow the prompts given by the machine. AED will charge and automatically shock the victim if necessary. Ensure that no one else is touching the victim to reduce the risk of bystanders being shocked.
• Following the initial shock, the machine will reassess the victim to determine if an additional shock is necessary.
• Continue CPR when prompted.
  

Chapter 13. Conscious Choking

Choking is caused when an object blocks the victim's throat or windpipe. For example, adults often choke on large pieces of food. However, children swallow small toy parts or other objects.

The universal sign for choking is mimicking choking yourself. First, ask the patient if they are choking because the person is merely coughing. If the patient is unconscious, call 911 and perform CPR.

Infants 12 months or younger

• Rest the infant on your forearm
• Perform 5 thumps with the heel of your hand upon the infant's back.
• If the patient is still choking, turn the infant over, face-up, and perform 5 chest compressions.
• Repeat the process until the object is removed.

Children and Adults

• Stand behind the victim.
• Lean the victim slightly forward and wrap your arms around their waist.
• Press hard with a closed fist into the abdomen, then grab your fist with your other hand.
• Perform five quick abdominal thrusts.
• Repeat the cycle if the object hasn't cleared the patient's throat.

Chapter 14. Unconscious Choking

If you are helping a choking victim and they lose consciousness, do the following steps:

For Unconscious Choking Adult or Child

1. Lower the victim to the ground
2. Begin CPR starting with chest compressions
3. Every time you open the airway to give rescue breaths, open the victim's mouth and check for the obstruction.
4. If you see the obstruction, turn the victim's head to the side and sweep it out of their mouth using your index finger.
5. Do not perform a blind finger sweep. This may push the object farther down the airway.
6. Suppose you do not see the object, attempt to provide breaths. If the chest doesn't rise, resume compressions.
7. Call 911 after five cycles of CPR
8. Check for responsiveness, normal breathing, and pulse if the obstruction is relieved.
9. Perform CPR if needed

For unconscious choking infant

1. Call 911
2. Place the infant on a flat, firm surface.
3. Perform CPR, starting with chest compressions.
4. Each time you open the airway to give rescue breaths, open the infant's mouth and check for the obstruction.
5. If you see the obstruction, turn the infant's head to the side and sweep it out of the infant's mouth with your index finger.
6. Do not perform a blind finger sweep. This may push the object farther down the airway.
7. Suppose you do not see the object, attempt to provide breaths. If the chest doesn't rise, resume compressions.
8. Check for responsiveness, normal breathing, and pulse if the obstruction is relieved.
9. Perform CPR if needed

Chapter 15: Recovery position

If the victim is breathing and has a pulse, put him in the recovery position while waiting for EMS to arrive. The recovery position will keep the victim's airway open, prevent the aspiration of fluids into the lungs, and allows fluid to drain from the mouth.

How to put the victim into a recovery position:

1. Kneel beside the victim. Empty any pockets to prevent objects from pressing uncomfortably on the victim.
2. Straighten the victim's legs and place the arm closest to you at a right angle to the victim's body. The victim's hand should fall toward and parallel to the victim's head. Lift the victim's chin to open the airway.
3. Move the victim's other arm across his chest. Place the back of his hand against his opposite cheek. Pull the victim's far leg up, bending at the knee with your other hand. Keep his foot flat on the ground.
4. Continue to use one hand to hold the victim's hand against his cheek. Grasp the victim's raised knee with the other hand and gently roll the victim toward you, onto his side.
5. You may need to use your knees to prevent the victim from rolling too far forward.
6. Tilt the head back to ensure an open airway. You may need to adjust the hand under the chin or the position of the top leg. Keep the top knee and hip and right angles.

Chapter 16: Airway Management?

Airway management refers to maneuvers and medical procedures to prevent and relieve airway obstruction. Airway management ensures an open pathway for gas exchange between a patient's lungs and the atmosphere. This is accomplished by either clearing a previously obstructed airway or preventing airway obstruction caused by the tongue, foreign objects, the tissues of the airway itself, and bodily fluids such as blood and gastric contents.

Airway management refers to maneuvers and medical procedures to prevent and relieve airway obstruction. Airway management ensures an open pathway for gas exchange between a patient's lungs and the atmosphere. This is accomplished by either clearing a previously obstructed airway or preventing airway obstruction caused by the tongue, foreign objects, the tissues of the airway itself, and bodily fluids such as blood and gastric contents.

Bag Valve Mask: A bag valve mask (BVM) or self-inflating bag is a hand-held device commonly used to provide positive pressure ventilation to a person who doesn't have normal breathing. The device requires resuscitation kits for trained professionals in out-of-hospital settings, such as paramedics. It is also frequently used in hospitals as part of standard equipment found on crash carts, emergency rooms, or other critical care settings.

Nasopharyngeal Airway: A hollow plastic or soft rubber tube that healthcare providers can utilize to assist in patient oxygenation. It provides ventilation in patients who are difficult to oxygenate or ventilate via bag-mask ventilation.

Laryngeal Tube: The laryngeal tube is an alternative to the anesthesia facemask. It is a potential tool for ventilation in patients with difficult airways. In addition, healthcare providers can use Laryngeal Tube during spontaneous or controlled ventilation.

Oropharyngeal Airway: An oropharyngeal airway or oral airway (OPA) is an airway adjunct used to maintain or open the patient's airway by stopping the tongue from covering the epiglottis. In this position, the tongue may prevent an individual from breathing.

Combitube: Also known as the esophageal tracheal airway or esophageal tracheal double-lumen airway, the combi tube is a blind insertion airway device (BIAD) used in the pre-hospital and emergency setting. Combitube is designed to provide an airway to facilitate the mechanical ventilation of a patient in respiratory distress.

Also known as the esophageal tracheal airway or esophageal tracheal double-lumen airway, the combitube is a blind insertion airway device (BIAD) used in the pre-hospital and emergency setting. Combitube is designed to provide an airway to facilitate the mechanical ventilation of a patient in respiratory distress.

Cricothyrotomy: Also called cricothyroidotomy, Cricothyrotomy is a procedure where healthcare providers place a tube through an incision in the cricothyroid membrane to establish an airway for ventilation.

Chapter 17: Management of Opioid-Associated Emergencies

Opioids are substances that act on opioid receptors to produce morphine-like effects. They are medically used for pain relief, including anesthesia. Other medical uses include suppressing diarrhea, replacement therapy for opioid use disorder, reversing opioid overdose, and suppressing cough.

How to identify opioid overdose?

1. Ask the bystanders. They may have information on the patient's actions before the collapse.
2. Examine the scene for drug receptacles such as syringes or bottles.
3. Observe the patient. Injection marks may indicate drug abuse, especially on the forearm.

CPR for patients with suspected opioid overdose:

1. Trained rescuers may perform both compressions and rescue breathing (artificial ventilation) for adults.
2. Untrained rescuers should perform hands-only CPR.

The algorithm for managing opioid overdose in children is similar to adults. The only difference is the method of CPR that is carried out. Both trained and untrained rescuers must alternate compressions with rescue breathing for infants and children.

Frequently Asked Questions

Are BLS and CPR the same thing?

CPR and BLS training typically requires keeping the victim's airway open, promoting blood circulation. However, the main difference between BLS and CPR is that BLS also includes lifesaving skills and techniques necessary for a medical or hospital setting, which is why healthcare providers often take this course.

What is the difference between adult and pediatric CPR?

With an infant, the rescuer uses his mouth to make a seal over the infant's mouth and nose. In chest compressions, the rescuer uses only one hand for a child and gently breathes. As for an infant, the rescuer only uses two fingers.

How do you provide high-quality compressions on a child during CPR?

To give high-quality compressions, push the chest to compress about 1/3 to 1/2 the depth of the child's chest at a rate of 100-120 compressions per minute. Let the chest rise completely each time. These compressions should be hard and fast with no pausing.

How long should a pulse check last?

The American Heart Association recommends checking the pulse for about 10 seconds. The ratio of time spent performing compressions to the total duration of CPR is 80% or higher, as these correlate with increased ROSC and survival to hospital discharge.

Why is it ok to give rescue breaths to an unresponsive choking INFANT even when you do not see the object, but not for a child or an adult?

It's ok to give rescue breaths to an unresponsive choking infant even when you do not see the object because the infant's airway is much smaller and can more easily become blocked by an object.

For a child or an adult, it is not ok to give rescue breaths if you do not see the object because the child or adult's airway is much larger, and it is less likely that the object will completely block the airway.

Why on opioid poisoning, if they have a pulse but are not breathing, you give Narcan, but if they do not have a pulse, you only consider Narcan?

According to the American Heart Association research, patients with no definite pulse may be in cardiac arrest or may have an undetected weak or slow pulse. These patients should be managed as cardiac arrest patients. Standard resuscitative measures should prioritize naloxone administration, focusing on high-quality CPR. It may be reasonable to administer IM or IN naloxone based on the possibility that the patient is not in cardiac arrest.

You should not delay access to more-advanced medical services while awaiting the patient's response to naloxone or other interventions. Unless the patient refuses further care, victims who respond to naloxone administration should access advanced healthcare services.

If I am the only person there after scene safety and activating emergency response, do I get the defibrillator and then start chest compressions if I am alone?

It's always recommended to perform at least 1 round of high-quality CPR, which takes 2 minutes. Then, you can obtain a defibrillator if you are alone. If the arrest was unwitnessed and you are alone, perform five cycles of CPR, then get the defibrillator ready. On the other hand, if you witness the arrest alone, you go for the defibrillators first.

What does the initial dose of 2j/kg mean in defibrillation?

2j/kg means you need to dial up 2 joules for each kilogram of the weight patient. When you look at a defibrillator, you will see a button called energy select or some variation. This is how you will select your joules to provide during each shock for the patient when necessary.

For example, if you have a child who weighs 20kg, you will dial up the energy to 40 joules (2 joules x 20 kg = 40 joules). Each subsequent shock (4, 6, 8) will require more energy. But do not go above 10 joules/kg.

Do you give breaths every 2-3 seconds or give breaths after every round of CPR for pediatrics?

It depends on the situation and resources. For example, if you are a single rescuer or 2 rescuers without a bag valve mask, you will perform breaths after each round of chest compressions. However, in the hospital setting, we have a bag valve mask and provide rescue breaths every 2-3 seconds for pediatric patients and every 6 seconds for adults.

Do you tap an infant's shoulder and not the underside of their foot

When checking if the infant is responsive or not, shout and gently tap their shoulder or flick the bottom of the foot. If there is no response and not breathing or not breathing normally, position the infant on his or her back and begin CPR.

Do you not need to put the patient in a recovery position to clear the airway first before CPR?

You can't perform CPR if the patient is in the recovery position. So basically, the correct order of action is to check blood circulation, airways, and breathing first and provide CPR if necessary. Then, once everything is stable, you put the person in the recovery position while waiting for the ambulance.

Conclusion

As healthcare providers, it is essential to remember that as real-life emergencies happen, the first order of action is to provide essential care techniques learned through the BLS course, call 911 and perform CPR until paramedics arrive. The participants in this course learn lifesaving techniques as solo or team rescuers.

This Basic Life Support Course aims to impart knowledge that helps healthcare providers provide Basic life support to individuals undergoing life-threatening medical conditions while the person is waiting for more advanced treatment in a hospital setting.